3850 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT N ONLY
BUILDING PROJECT IDENTIFICATION �IPERMITumREP
So LDINGAPPLICATION & PERMIT3850
PDNESsBUILDING - ELECTRICAL-PLUMBING -MECHANI
OWNER'S PLAN CHECK VALIDATION
,(
NAME
(� U DTV. ELECTRIC PERMIT FEE
Y\. mH2 PHONEY - /
CONTRACTOR'S
UTLETS-SWITCHES-RECEP 5.00/1.00
sec.No. LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S It PPL LANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 5.00 GATE OF APPLICATION
ts,< ARCHITECT - PLAN CHECK FEE P.C.NO.
OR SIGNS 6.00
ENGINEER
LIC.NO SIGNS TRANS. 3.00
ARCHH.OR ENG SPECIAL CIRCUIT •5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00 41 /
APPLiDRCESS $ MOTORS SEE FEE SCH. "ADDPESESERVICE CHANGE 10.00 S4300 0 LICENSED CONTRACTORS DECLARA'T'ION
a U I hereby affirm that I am licensed under provisions of Chapter 9 S NCE DATE .!
t-< N (commencing with Section 7000)of Divi ion 3 of the Rusine un E L MECH.
H w z Professions C a se is in full an ❑ ❑
im o Llcen Clas Lic.Numbe
H
m w Data Contractor
Q w a OWNER-BUILDER D L ATI-ON _ INFORMATION
AIT
-xa ;u N I hereby affirm that I am exempt rom the CMISC. REFER TO ORD
Contractor's License yn LUATION S/FT.
r LL 0 a Law far the following reason.(Sec.7031.5,Business and Professions -PERM IT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,alter, /-
re R¢p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
wO LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO t 61
$ he is licensed pursuant to the provisions of the Contractor's License
r z a Law(Chapter 9(commencing with Section 70000of Urvision 3 ofthe
4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE T
re I- $ the basis for the alleged exemption.Any violation of Section 7031.5 - ?'ES TYPE CONSTR.
u ; _ by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00 ^/-e•.�� f �ra
of not more titan five hundred dollars($500).):
❑ I,as owner of the property,or my employees with writes as BACK F LOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTALACREAGE
• himself or through his own employees,provided that such improve-
menta are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4,00
or improvement is sold within one year of completion,the owner GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE PES IND CON pit Omer
builder will have the burden of proving that he did not build or im- E
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ -CO O
❑ I,as owner of the property,am exclusively contracting with ED
licensed contractors to construct the project(Sac, 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code.The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,roil who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 PCC.DATE ACC.FILE NO.
WORKERS'COMPENSATIO ECLA RATION WATER TREATING EQUIP. 4.00
I hereby affirm that I ha' t' of consent to sal Ginsurc' ZONING ENG.SITE NO.
or a certificate of W r� pensal' n Insurance,or u c ied
copy[here a C.
Policy No. Cmnpan
O ❑ Cer]ifi apy is here by turn ed. FIRE SPRINK ENERGY T 24
❑ Ccrtifi d ro 'ix ti be c' in: e t division. MISC.- REFER TO OR D.
Z O Applicant V N Y "❑
a C:RTIF CA'ITOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOODZONE AL.0 C.
W COMPENSATION INSURANCE PLG.CONTIT LIC.NO. PLG, v N v N
CL O This section need not be completed if the permit is for one TOTAL
D 2 hundred dollars($100)or lest.)
V O 1 certify that in the performance of the work for which tis per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL P mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California. r (yp
Ed Date APPlicamBUILDING
ALTER OR ADD TO MECH. 4.00
} m NOTICE TO APPLICANT: It,after making this Certificate of Ex-
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the labor Cade, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10)000CF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE SO
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city,and county PLUMBING
ordinances and state laws relaling to building construction, unit
BOILER-COMPI3 H.P.Dr 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000.BTUI SEE FEE SCH. MECHANICAL
a ove-mentioned property for inspection purposes. -
We) agree to Suva, indemnify keep harmless t 'ty of MISC.- REFER TO ORD.
Cu How against liabilities,jail a s, costs J Bose hick. - CONST.TAX
ma in any way accrue egos t W City i o eque of the PERMIT ISSUANCE 3.00 Fs
gr' t g of this permit. MECH.CONT. LIC.NO. TOTAL V
TOTAL Sy _
r of Applicant/ ontrador Date
OFFICE COPY