11109 GO* -ARAoJ4-k
APPLICANT TO FILL IN INF•v1ATION WITHIN RED LINES - USE " ALL POINT PEN ONLY
BU LDING PROJECT IDENTIFICATION qW PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 1110
OWNER'S PLAN CHECK VALIDATION
OTY. ELECTRIC PERMIT FEE
L aN �P
CONTRACTORS ) oIRH�Is , (1� '`i` UTLETS MN
ITCHES 10.0011.00
uNSCs.7XSP-td (- '':'SLIC.No `05 2 LIGHTING FIXTURES 10.00/1.00
I -DNTRACTORS`- -' 4k5 APPLIANCES-RESIDENTIAL 4.00
9-7^t40 PANELS 10.00 DATE OF APPLICATION
ARCHITECT ( '�� �tkk PLAN CHECK FEE P.C.NO.
OR 1`(l PANELS (OVER 200 AMPI 20.00
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRE5R ENG. C1� s \ rn� L y�r SPECIAL CIRCUIT 5.0D PERMIT VALIDATION
�`(, .Jill C'xGZIlvy.l.-? EMP.METER OR POLE INS. 20.00
ADDRESS G^ MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
00 LICENSED CON TRACTORS DECLARATION -
G o u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
m G m (commencing with Section 7000)of Division 3 of the Business and L wt,.. BLDG. ELECT, PLG. MECH.
H w z Professions Code a my license is in full forty bpd e el[
z o T- License Class ' Lic.Number 2 r T toS
,o w H Da[c Contractorriin
¢ y s Z (D. City Ot CUPeBUILDING PERMIT
¢ ¢ w ¢ OWNER-BUILDER DECLAR INFORMATION
" REFER TO ORD
w 3 LL N 1 hereby affirm that I am exempt from life Contractor's License MISC.- VALUATION $/FT.
H a- o a Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
aa Q Q improve,demolish,or repair any struct Ure,prior to its issuance,also EL G GGNER. LIC.pN0�,�.C' ELEC.
ce ¢ requires the applicant for such permit to file a signed statement that �^� W W5 TOTAL 5�J PERMITTO
wm he is licensed pursuant m the provisions of the Contractor's License //---
HZQ Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe �^-LE'1✓-
E o Business and Professions Code)or that he is exempt therefrom and QTV. PLUMBING PERMIT FEE
the basis for lire alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a3E by any applicant for a permit subjects the applicant ton civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($5000.):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 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. 5.00
Code:The Contractor's License Law dols not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 S0.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.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 Or im-
proveforpurposeofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct life project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law dos not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 _
contracts for such projects with a commetmDO licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10DO
Che Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sc,.-,B&P,C.I'or this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to sell-insure, ZONING
or a certificate of Workers'Compensation Insurance,or a cerci Gad ENG.SITE NO.
copy therco $ 3800, G
PolXo C omPany_
_,Z
O NriBed
copy is hereby furnished FIRESPRINK ENERGY T24
Z Z ❑ Certified copy is Bled with the city inspection division.
O Applicant MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑ .
CC = CERTIFICATIi OI'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOOZONE A.LUC.
LL > C04ENSATION INSURANCE PLG.COINER. LIC.NO. PLG.
Z (This section need not he completed he permit R for one TOTAL V❑ N❑ Y ❑ N❑
hundred dollars($1000 or less.)
U O I certify that in the performance he work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,1 shall not employ person in any manner so as to
Ulu become subject to the Worker' onrpensation Laws of California. BUILDING
tL Date Applic' ALTER OR ADD TO MECH. 5.00
} to NOTICE TO APPLIC If,after making this Certificate of F-x-
♦- Z emption,you sho ecome subject to the Workers'Compensation APPLIANCE 5.00 - PLAN CHECK
Pori
of e Labor Code, you must forthwith comply with - FEE
U such pro ns or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
o CONSTRUCTION LENI),Ik AGENCY AIRHANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby of fimI that there is a c Ietion lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work fo rhich this permit is issued(Sec. MICROFILM
3097,Civ.C.), HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
1 certify that 1 ve read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
information is ¢eat. 1 agsee to comply with all city and county PLUMBING
ordinances and store lows relating to building mnstmdion, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hcrcby authmsentalives of this city to enter upon the
a •-mentioned proper Inspection purposes. BOILER-COMP(Over tOo,oOO BTUI SEE FEE SCH. MECHANICAL
( nee to save, nden ify and keep harmless the City of MISC.- REFER TO ORD.
uper o just Babili 'es,jug nts, costs mId expenses which PERMIT ISSUANCE 10,Op CONST.TAX
ay f a accru againsty in col sequel ce Of lire
an[ O -r Ifl1 MECH.CONT. LIC NO. - MECH. ('
TOTAL TOTAL �do�✓
Si ppliean[/ on actor ate
OFFICE COPY