17645APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUIL NG PROJECT IDENTIFICATION
APPLICATION &PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
q'
17645
BU I LDING
ADDRESS
West Estates Dr.
OWNER '$
NAME
David Morris PHONE 446-5883
DTV. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
�O�
DATE OF APPL ICATION
NAMEPAcroPs
Valentine Corp. LIC.ND. 229225
OUTLETS -SWITCHES -RECEP 10.00/1.00
ILIGHTING FIXTURES 10.00/1.00
no9S'SanRa Rafael
111 Pelican Way(A&5)453373
PPLIANCES-RESIDENTIAL 4.00oESTOPs
PANELS ,10.00
ARCHITECT
on
E"4VY" Les Marquoitm.No. 17810
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
.,
SIGNS TRANS. 3.00
ADDRESS ENO ' Danville
44 Leeds Ct. E. Ell
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
2��5 Gly
L
ISSUANCE DATE
TEMP. METER OR POLE INS. 20.00
AIPLICA
Anon .. Pelican Way
San Rafael, CA 94901
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
I hereby al'Enn that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Cod' �d my license n in full for ar fj4
License Class -& Lic.Number_G-<,`1-
Date Cnntrucmr
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt Isom the Contractor's License'
Law Icor the following reason. (Sec. 7031.5. Business and Professions
Code: An -t or count -
Any County my structurep prior
hetapplic Or repay any structure, tole, prior n Its statement
requires such permitns offfile avgnedact.,', Li that
that
ley islesoled applicant pursuant
ht is licensed 9 (C., nl ce the provisions of Eta Contmctrr's License
troutaw s .it Pmeonimencinde) or thation]000)of ofthe
that heixexempttherefrom and
and
Business for
JPe alleged exemption.
the buil for the alleged exemption. Any violation of Section 7031.5
by any applicant lora permit dollars SSire app]icannoacivil penalty
malty
five hundred dollars lmy em :
of not more tl owner
❑ Las owner at the willproperty,ti or my employees with wager as
their sole compensation, will do the work, and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
property who builds Or Improves thereon, and who does Such work
hinoself or through his own employees. provided that such improve -
mentsare not intended orofferedfor sale, If. however, the building
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or ice-
Prove fors owner of salo).
❑ d as owner of the property, ono project (S, contracting BLI with
]sneered contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law docs not apply
to an owner of property who builds or improves thereon, and who
commcls for such projects with a contractool) licensed pursuant to
the Contractor', License Law,
❑ lam exempt under Sea ,B.&P.C. for cels
reason _
Owner DTA
-
BLDG.
ELECT.
PLG. MECH.
BUILDING PERMIT
INFORMATION
MISC. - REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
t✓
S/FT.
ELEC. CONTR. LIC. NO.
TOTAL
TOTAL
PERMIT TO
x _ s
IPJ
DTV. PLUMBING PERMIT FEE
ALTER-DRAIN-WATER(EA.) 5.00
STORIES
TYPE CONSTR.
BACK F LOW PROTECT. DEVICE 4.00
DCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
FIXTURES - PER TRAP 5.00
SQ FT. FLOOR AREA
TOTAL ACREAGE
GAS-EA.SVSTEM-I1NC.4OUTLETS 6.00
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB Cool,
❑ � ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 6 (EA.) 1.00
SEWER -SAN ITARV-STORM EA. 200ft/10.00TRACTNO.
PARCELNO.
WATER HEATER W/VENT 6.00
Date
WO RKHRS'COMPF:NSA'NON DIiCLA RATION
1 hereby affirm that I have a cerdfcute ofpon,rm to self -insure.
or a certificate of Workers' Co,gt}5 t, I a certified
copy thcly�Aob8�, Lab.C.i"" y-C� 0 �
PercyN. mpany_4.�M1Ydl],Qe
❑ CertilicJ copy iF hereby furnished.
XX Certifigd copy is fled wiih the city inspection division.
npplfant c T-
%' CERTIFICA'1'17 OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
I Phis Section need not be completed if the permit is for one
hundred dollars IS 100) or less.)
1 certify that in the performance of the work Icor which this per
mit is issued, I shall not employ any person in any manner so as to
become subject to the Workers Irpinmenuron Laws of California.
Dak_ie-rKAPPLICA iF:i
,NOTIC o '1 Should become
If, utter making this ,,' C scute of iEs-c,
provision you tiro L become subject m the Workers' c mp comply
provisions of the Label Code, you must forthwith comely with
with
such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby uffnn that there is .'Construction ]ending agency for
the performance of the work for which this permit is issued (Sec.
3097, Civ C.), None Known
Lender's Name
WATER SYSTEM 5,00
ACC. DATE
ACC FILE N0.
WATER TREATING EQUIP. 5.00
ZONING
ANG. SITE NO.
-
MISC.- REFER TO ORD.
FIRE SPRINK
y NE]
ENERGYT-24
YE) N�
PERMIT ISSUANCE 10.00
FLOOD ZONE
Y N
A. L. u.c.
Y [:] N[
PLG.CONTR. LIC. NO.
PLG.
TOTAL
DTV. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
t -
ALTER OR ADD TO MECH. 500
APPLIANCE 5.00
PLAN CHECK
FEE
Lt'
AIR HANDLING UNIT (TO IOMC-F.M,) 4.00
AIR HANDLING UNIT (OVER JOSWC.FM.)6.00
SEISMIC FEE
['�,
•� `
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Address
I certify that I have ... d this applicutlor and state that the above
information is correct I agree to comply with ail city and countyPLUMBING
ordinances and state laws relating to building construction, and
authorme representatives of this city m enter upon theabo,mentiuned Property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of
against liabilities, judgments, costs and expenses whichCONST.
may in any way accrue against said City in consequence of the
of this permit'
NIT (OVER 100,000 B. T, U.19.50
ELECTRIC
N FAN (SINGLE) 4.00
P(3 H.P, or 100,000 B.T.U.) 6.00hereby
P ( Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
MFAN
REFER TO ORD.upertino
TAX
��,�meting
UANCE 10.00
MECH. LIG NO. MECH.
TOTAL
TOTAL
'ignature of Applican on ,actor ate
OFFICE COPY