4337 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT n
ADD E - �� ) r
IIW1� BUILDING-ELECTRICAL-PLUMBING -MECHANIC
Ow E PLAN CHECK VALIDATION
OTY. ELECTRIC PERMIT FEE
[//
CO T ACTORS 9---(/ �/
NA �/1OUTLETS-SWITCHES-RECEP 5.00/1.00 / 3
ic.rvo. ICI LIGHTING FIXTURES 5.00/1.00 PAID
CONTRACTORS
AODR s �j���.•� APPLIANCES-RESIDENTIAL 4.00 (�fi'1n�'1IT •� Q
.St orvEr ( PANELS 5.00
SIL
O App
LI
oe HIT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.No. SIGNS TRANS. 3.00 City Of CiUpQ IQQ
ARCH.OR E
ADDRESSc. _ SPECIAL CIRCUIT 5.0Q PERMIT VALIDATION
21 EMP.METER OR POLE INS. 15.00 \ �M
APPLICANT'
ADDRESS MOTORS SEE FEE SCH. 1
-SERVICE CHANGE 10.00
woo LICE NSEDCONTRA RS DECLARATIO.
<u he by affirm that I am licensed under provisions of Chapter 9 bbb
H G w IC amt ting with Section 7000)of Division 3 U(thc Business and - , ISSUANCE DATE
F m z Pn
exist
ns Co a se is in full fo a an t.
BLD ELE T. PL MEC .
z o ut - Li,,s, I'ss
Lie.Numb, ,OCT
9 m 1- w DatContractor 1 1963}
p Z a OWNER-BU DER DECLARATION BLnLDING VERMIT
a 0 a " MISC.- 'ORD INFORMATION
x, g r I herehy altirin that I am exempt from Ilm Comrucmr's License
Fe_ Law for the following reason.(Sec.7031,5.Business and professions - PERMIT ISSUANCE
/ VALUATION S/FT.
Code:Any city orcounty which requiresa permit to construct,alter,
6.00
A sr FO improve,demolish,or repair any structure,prior to its issuance,also E C.CON R. LIC.N ELEC.
A m ic rectums the applicant for such permit to file a signed statement that TOTAL
w he is licensed pursuant to the provisions of the Contractors License PERMIT TO
F e Law(Chapter 9(commencing with Section 7000)of Division 3 of the
4 O Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
I $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES T PE CONSTR.
a byanyapplicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN VENT-WATER IEA.) q,00
of not more than five hundred dollars(S500).):
❑ Lemployees as owner the property,or my emoyees with wages as
their sola compensation,
ion,will do the work. pl the structure is not BACK F LOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,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 L
hinhsell'or through his own employees,provided that such imsD.Fr.FLOOR AREA TorAACREAGE
prove..
menu are not lnteadedoroffered forsale.lLhowever.the building GAS-EA.SYSTEM-11NC.40UTLETS 4,00
or improvement is sold within one year of complel ion,the owner-
. builder will have the burden of proving that he did nn1 build or all- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
prove forpurpnsc orsale.). INDUSTRIAL WASTE INTER. 20.00 IAl ❑ ❑N ❑ O❑
❑ 1,as owner of the property,um exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Busine,s LAWN SPRINKLERS-1 INC 5 VB500 ASSESSOR
and Professions Code:The Contractor's License Law does not apply . . . S PARCEL NO.
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 contractors)licensed pursuant to
[lie Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec ,tl.&P.C.far this WATER HEATER W VENT
reason / 4,00
Date Owner WATER SYSTEM 4.00
ACC.DATE ACG FILE NO.
W'ORKERS'COMPENSATION'DECLARATION WATER TREATING EQUI AI 4.00
I hereby affirm hat I have a Certitica4 of consent w seg f-insure,
or a cartificalc rkers'Compensation Innuancc,or'v Calif icd ZONING ENG.SITE NO.
copy thereof ec.3 00,Lab.C.1.
Policy No. Company
o Cer lied copy herebyfur shed. RE SPRINK ENERGY Z Z Cer'Ocd cop filed h 'h' ci di o 24
Applluuv MISC.- D. v ❑ N v ❑ NNE]~ NO IPER IT ISSUAN E
� - CER'I'IIICA' ?pF'I?XIiN1970N FROM W( RKIiRS' 6.00 FLoODZONE A.L.U.C.
W C M1I PENSATION INSURANCE P C. PLG.
CL O (This section need not be Completed if the permit is liter one TOTAL V E] N E] v E] N❑
U O hundred dollm,($100)or less.)
I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued. I shall not employ any person in any manner so as to
hecmnu subject to the Workers'Compensation Laws of California.
UJ Date Applicant ALTER OR ADD TO MECH. q,pp BUILDING
} Z NOTICE TO APPLICANT: If,after making this Certificate of Es-
_ emotion,you should become subject to the Workeri Compensation APPLIANCE 4.00 PLAN CHECK
V
provisions
provisions of the Labor Code, you must forthwith comply with
permit shall be deemed revoked. AIR HANDLING UNIT(TO 1Op00GF.M.) 3.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE 2
I hereby affirm that there i a cons uaiun lending agency litr EXHAUST HOOD(WITH DUCT) 2.00
The performance nl the war r whi this permit is issued(Sco. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lenders Address H EATI NG UNIT(OVER 100,000 B.T.U.)7.50
ELECTRIC
I certify that I have read thi application and stu1e th:t the above VENTI LATION GLE) 3.00 /JfJ
information is correct, I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction. and BOILER-CC) 3H.P. 100,0008.T.U.) 4.00
he rch utlmri,e representatives of this city to enter upon the BU LER-
aho •-Fir ntinned pr,Pe,yform,PeeIi.mpmjmw,. Ip q 1SEE FEE SC H. MECHANICAL
We) ,e m save, indemnify and keep harmless the Cit'of MISC.- ' f
C pert lost liabilities,judgments, h REFER TO ORD.
By g j t said , costs and expenses which ERMIT IS U A IAO CONST.TAX
y i n a accrue against said City in nseq uence of the p 3.00
g anti g tf I 1 nail. EC f ONT. LIC.N0,
MECH. C'\)
TOTAL
Sigh p many/'onset., Dat L�" TOTAL �Z
OF CE COPY