12536 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI, POINT PEN ONLY
;;i° PERMIT NUMBER
FADORtSS
LDING PROJECT IDENTI FICATIO! APPLICATION & PERMI t
`w 12536
BUILDING- ELECTRICAL-PLUMBING-MECHANICALPLAN CHECK VALIDATIO17.N �,f �.rJP�J // /�(� J� OTV- ` �uELECTRIC PERMIT,?. FEE
/ ///``�wPON 'J /4�J�1J' .OR'S ' UTLETS-SWITCHES-RECEP10.00il.00I
w. 4LyDE ��ic ���L uc.No. 'i J"3wi LIGHTING FIXTURES 10.00/1.00
'CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
OREss 'f /`J)
PHONE 1(Jl` PANELS 19
'DU DATE OF AJPUCATION
AO
ARCHITECT PANELS (OVER 200 AMP
I PD.00 PLAN CHECK FEE P.0.N0.
DENGINEER LIC.NO. SIGNS TRANS. 3.00
ON
AENG. SPECIAL CIRCUIT 5.00 ( PERMIT vnu Dnr'V
ADDRESS
ss
zIP EMP.METER OR POLE INS. 2C•.00 -
APPLICANT S MOTORS SEE FEE SCH.
ADDRESS / p,
SERVICE CHANGE 20.00 � 3I b
0. z LICENSED CONTRACTORS DECLARATION 1D
w H
u v I hereby affirm that 1 am licensed under provisions of Chapter ISSUANCE DATE
v,<vAi (commencing with Section 7000)of Division 3 of the Business and ( -�f BLDG. ELECT. PLG. MECH.
F m z trio
Code,and my license is in full force and effects L' ❑ ❑ ❑ El
z o T - icense Class Lie.Number
9 y ° Date Contractorll Q�I(1Q ('i6U-ING PERMIT "p,
In w OWNER-BUILDER DECLARATION REFER TO ORO "�' 'INFORMATION _sw-ii v
w 3 LL H I hereby affirm that I am exempt from the Contractor's License MISC.- VALUATION S/FT.
j Law for the following reason.(Sec.7031.5,Busincssznd Professions PERMIT ISSUANCE 10.00 (�
„i Code:Any city or county which requires permit to construct,alreL ELEC.CONTE. LIC.NO.
ac¢¢o improve,demolish,or repair any structure,prior to its issuance,also ELEC. �„{
-o¢ requires the applicant for such permit to file a signed statement that TOTAL CSV I PERM TO
he is licensed pursuant to the provisions of the Contractor s License - T M p
< o /C /, 6LC�
Hza
Law(Chapter 9(commencing with Section 7000)of Division 3 of the - fya a PLUMBING PERMIT FEE
E 4 o Business and Professions Code)or that he isexempt therefrom and QTY. i}. ( rte' - r STORIES TYPE eONSTR.
¢F m the basis for the alleged exemption.Any violation of Section703L5 '0-•' 1
by any applicant for a permi[subjects the applicanuoacivil penalty AL - RAIN&VENT- TER IEA.1.5.00
AI' of not more than five hundred dollars(S500).):
❑ 1,as owner of the property.or my emplovees with wages as ACK FLOW PROTECT.DE ICE 4.00 I OCC.GROUP RES.urvITS
[heir sole compensation,will do the work,and the structure is not
e intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,ARE ,GOND. 5.00
Code:The Contractor's License Law does not apply to an owner
property who builds or improves thereon,and who does such ork FIXTURE -PER TRAP 5.00 1 5p,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such i prove- GAS-EA. TEM- INC. OUTLETS 6.00
ments are not
intended Or offered for sale.If,however,t building
or improvement is sold within one year of completio the owner- GAS-EA. TE -OV E 4(EA.1 2.00 BUILUING USE
.builder will have the burden of proving that he did n t build or int- RES IND CON• RB Omar,
:rove for purpose of sale.). INDU R A WASTE I ER. 30.00 ❑ 1:1 ❑
❑ I,as owner ofthe property,am exclusive) contracting with
-, -licensed contractors to construct the project( cc. 7044,Business L P KLERS- INC5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's Licens Law does not apply
to an owner of property who builds or mal ves thereon,and w L W INKLER -OVER 5(EA.) 1.00 s
contracts for such projects with a con tncD s)licensed pursuant
R-SANITA -STORM EA.200ft/10.00 TRACT NO. PARCEL rv0.
the Contractor's License Law.
❑ 1 am exempt under Sec. .B.&P.C.for lh ATER HEAT R W/VENT 6.00
reason
Owner Date WATER SY EM S.00 ACC.DATE ACC.FILE N0.
WORKERS'COMPENSATIO DECLARATION WATER EATING EQUIP. 5.00
I hereby affirm that I have a certifi to of consent to se -in ZONING I ENG.SITE NO.
or a certificate of Workers'Compensa on Insurance,or a crit ed
X copy thereof(Sec.3800,Lab.C.).
Policy No. Company /
O ❑ Certified copy ishereby fumishe . FIRE SPRINK ENERGY T"i<
Z Z ❑ Certified copy Is filed with t city inspection division. MISC.- REFER TO ORD. Y LJ NLJ I Y N�
F- �f Applicant
r` PERMIT ISSUANCE 10.00 FLOOD ZONE A.LU.C.
(r - CERTIFICATE OF EXEMPTION OM WORKER '
ELI > COMPENSATION INSUR CE PLG.CONTE. LIC.NO. TOTAL Y� N� Y❑ N�
CL O (This section need not be completed if th ".it is he
Z hundred dollars(S 100)or less I ;fiy'Q;. `�'.y' --as 'Os'iy ?n,A '
U O I certify that in the performance of the work for which this per C r'$r FEE
Q�.T_gY'. . MECHANICAL PERMIT'I+nr^•,.e..
<L )- mit is issued.I shall not employ any person many manner so as to v .-l ,W T-,-,.)T# :�,ta y > 6;
Ow become subject to the Workers''Compensati^n Laws of California. - BUILDING
Date Applicant ALTER OR ADD TO MECH. 5.00
} M NOTICE TO APPLICANT: 11,after making this Certificate of En 5.00 PLAN CHECK
I.- Z unption,you should become subject to the Workers'Compensation APPLIANCE
provisions of the Labor Code. you must forthwith comply with AIR HANDLING UNIT(TO 1QOODCF.NL) 4,00 FEE
U such provisions or this permit scull be deemed revoked.
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency fur EXHAUST HOOD(WITH DUCT) 5.00
the pe,hurpance of the work for which this permit is issued(Svc. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.C.).
bender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC 34
• _ Lender's Address
I certify that I have read this application and urate that the above VENTILATION FAN (SINGLE) 4,00
information is correct. I agree to comply with all city and county BOILER-COMP(3 H,P.or 100,0006.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction,and
/ hereby authorise representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
abovementioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
CuPetunia against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in nseq.Cnce of the „
gmn[In >I this permll. MECH.CONT. LIC.NO. MECH.
,` TOTAL iir
\ ' �r L OTAL
xnature n- ppli>�Con«actor Date