16961,�,1 W' APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -.USE BALL POINT PEN.ONLY
7- ' BUILDING PROJECT IDENTIFICATION - - PERMIT NUMBER
a°"°'"° /o/f o �E'A977a <7 1ulp APPLICATION & PERMIT ' 6961
AD°REaS 6�7 U
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
owNEWs
NAME' QTY. ELECTRIC PERMIT FEE/�Q - PLAN CHECK VALIDATION
pl/ /�
•� I av" PHONE
CNTNAMEgACTDR's - OUTLETS-SWITCHES-RECEP 10.00/1.00
/I/e-12 LIC.No. S-Z LIGHTING FIXTURES 10.00/1.00 450
CONTRACTOR/'� 2-•5-a
O0R ISCG .Q V V ( APPLIANCES-RESIDENTIAL 4.00
PHONE _/ .L .PANELS 10.00 DATE OF APPLICATION
AR
CHITEG7PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.ND. SIGNS TRANS, 3.00
ADDRESS ENG.
- SPECIALCIRCUIT 5.00 PERMIT VALIDATION
�,.�ZIP TEMP.METER OR POLE INS. 20.00 \`��je`•"`z/NCS
Ae -e �S� MOTORS SEE FEE SCH. L
ADDRESSDDRESS /d
SERVICE CHANGE 20.00
LIDO
ao LICENSED CONTRACTORS DECLARATION
F i W I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
of< ,AA BLDG. ELECT.I PLG. MECH.
r w Z Professions Code ad nm license is in full force'md e e l�2 t
Z o m- License Class Lie.Number
o v,H Date \ Contractor �f
s s ¢ 'OWNER-BUILDER DECLARATION
C/ty l L BUILDING PERMIT
w U INFORMATION
X ;LL I- I hereby affirm that I am exempt from the Contractor's License MISC.- EF ER TO ORD
ut ,T 17, VALUATION
a o< Law for the followingreason.(Sec.7031.5,Businessand Professions
r _ m PERMIT ISSUANCE F
ac2 Code: y city or county whiny requires apermit to construct, also
Q T< O improve,demolish,or repair any structure,prior)o its issuance,also ELEC.CONTR. LIC.NO. ELEC ' r Ih/e'1
a w m u ' requires the applicant for such permit to lite a signed statement that TOTAL 00 PERMIT TO
he is licensed pursuant to the provisions of the Contracui License
HZQ
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
fi D Business and Professions Code)or that he is exempt therefrom and GTY. PLUMBING PERMIT FEE
Ic r m the basis for(he alleged exemption.Any violation ofseclion 7031.5 STORIES TYPE CONSTR.
a ; ,- by any applicantfor a permit objects(he applicanttoo civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500)):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP REB.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,AREA,GOND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves heocon,and who docs such work F IXTURES-PER TRAP 5,OD
SD.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such inyvova
menlsare through
et or offered Res,or provided
Ilcu such
building GAS-EA.SVSTEM-I1NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have
the burden of proving that he did not build ar int-, RES IND CON PB Omer
prove for purpose ofodc). INDUSTRIAL WASTE INTER. 30.00 El ❑ 11 11 F-1❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sea 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs not apply
to an owner of property who builds or improvesthereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts forsueh projects with a commemr(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO
❑ I am exempt under Sec. ,B.&P.C.for this - WATER HEATER WIVENT 6.00
reason
Owner Date WATER SYSTEM 5.00
- ACC.GATE ACO.FILE N0.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
'1 hereby affirm (hut I,heve a certificate of consent to self-insure, ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec.3800,Lab.C).
Policy No. Company -
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
-Z Z ❑I1 ❑ N❑ V ❑ N❑Ccrtified copy is filed with the city inspection division. MISC.- REFER TO ORD. Y
I- O A
�+ 10.00 FL000 zoNE A.L.u.c.
CIiRTI PI CATIiE EXEMPTION FROM WORKERS' ISSUANCE
LU '
W �f•- 'COMPPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL 0 (This section need not be completed if the permit is for one _ TOTAL Y❑ N❑ V❑ N❑
Z) Z hundred dollar,IS 100)or less.) -
U O I certify that in the performance of the work for which(his per- FEE SUMMARY
W 1- mit is issued,1 shall not employ any person in any manner suits to GTY' MECHANICAL PERMIT FEE
O W become subjecIt Q a Workers'Compensation ws of Cal ilo ia.
} d DlncJl+l,�¢OApplicam� ALTER OR ADD TO MECH, 5.00 BUILDING
m NOTICE TO AI'1'LICANT: If,after ma m (S is Cerl it is of lix-
Z. emption,you should become subject to the Workers'Compensauon APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
_i U such provisions or this permit shall be deemed revoked, AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 6.00 SEISMIC FEE
I hereby affirm fled there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
Ilia performance of the work for which this permit is issued(Sec. MICROFILM
3097,CN.C,), HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address HEATING
'0,00
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING.
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
no against liabilities,judgments, casts and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
- nayay in any way accrue against said City in consequence of the
ranting Of this permit MECH.CONT. LIC.NO. MECH.
tx /a- � TOTAL TOTAL ��'co
Signature of Ap f leant/Contrac(o Uate
OFFICE COPY