3783 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
IhiBUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT PERM NUMBER
BIILDING ...
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� � '• �pV-(}.ITEC E1:PN/Y BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 3783 -
OWNER'SDI� � - PLAN CHECK VALIDATION
NAME
t* koRc14K-/ sUSi, sli-4wOTY. ELECTRIC PERMIT FEE
PHONE �i
NAMERACToea OUTLETS-SWITCHES-RECEP 5.00/1.00
X C
�.S.JT�I�kD 10�J>�L U"GL2Cj,c. o,/267i/2i LIGHTING FIXTURES 5.00/1.00
x ADDREAc7ons PPLIANCES-RESIDENTIAL 4.00
AQO.O.,R�Eyss ,. ��f��']��� Q�� /-r
]IA�J �Q E.:.rr ILPOp`YRONE 'yya-_I'`7 PANELS - 5.00 DATE OF APPLICATION
ARCHITECTPLAN CHECK FEE .C.NO.
OB ENGINEER ?C�035"' SIGNS 6.00
EN
uc.No. SIGNS TRANS. 3.00
rA.00 ess ENG' SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00 /
AvRIESS s
AoDREss MOTORS SEE FEE SCH. L�
O
SERVICE CHANGE 10.00 0/ )
oi
0
Foo LICENSED CONTRACTORS DECLARATION
a o u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
I
z$ (commcncing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
Professions Cycle,rd m license is in full for a J f ❑ ❑ ❑ ❑
Al - LicensSClass`-��(.ate_Lic.Numbs
O r Date
O- YJ Y3S Contractor
P:
x s .+ BUILDING PERMIT
a OWNIi R-BUILDER DECLARATION
a o> INFORMATION
w 3 LL I- I hereby affirm tlut I am exempt from the Contractors License MISC.- REFER TO ORD
HP_ Law for lire following reason.(Sec.7031.5,Nusinessand Professions pERMIT ISSUANCE ATION S/FT.
Code:Any city or county which requfreSu permit to construct.alter, 6.00
QP, ¢ p improve,demolish,or repair any structure,prior to its issuance,alw ELEC.CONTR. LIC.NO. ELEC.
E:
requires the applicant for such permit to file a signed statement that TOTAL Al I MIT TO
s. K
m he is licensed pursuant to the provisions of'the Contractor's License A /A-f79 e_
rz > Luw(Chapmr9(commcncingwith Scdinn 7000)af Division3nf lhU s _
Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FK-'vK _c
IS Ia. $ the basis for the alleged exemption.Any violation of Section 7031.5 STUDIES TYPE CONSTR.
d � by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than Five hundred dollar,(S5001.1:
❑ 1,as owner of the property,or my cmployccs wish wages as BACK FLOW PROTECT. DEVICE 2.00 OCC. RES.UNITS
Irvin sole compensation,will do the work,and the structure is not
intended or offered for sale (See. 7044. Business and Professioos DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code:The Contractor's License Law doss not apply to an owner of s
properly who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 4.00 so.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own em Noyccs,provided that suC11 improve-
ments are not intended or offered for sale.IL however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or improvement is sold within one year of completion, dm owner - -GAS EA.SYSTEM OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or in, RES IND CON PB Omer
prove for purpose of side.). INDUSTRIAL WASTE INTER. 20.00
❑ Las owner of the properly,um exclusively col trueGng with - 11 ❑ ❑ 0
licensed contractors to construct the project(Sec 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B.
and Professions Code:The Contractors License Lau'dues not apply' 5.00 ASSESSORS PARCEL NO.
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for.suit,mawrrs wish a°ontraclons,licensed Pornmin to
the Con r,cvr's L,,vnsc Lew. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lI,mexamptundcr Sec. .B.&I'.C.forthi WATER HEATER W/VENT .4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE Ace FILE NO,
WORKP-RS'COAIPENSA'I'ION UECIARAT ION WATER TREATING EQUIP. 4.00
I hereby affirm that 1 have a certificate ofconsent to self-insure.
or a certificate of Workers'Com Pen Non Inance,or a certified ZONING ENG.SITE NO.
copy'yjr Il f�go,/.ab.C.l.
roue)/Cf1oSC .ctrl rang S
O crtilic�1�_7o Is her by�lu , cJ.
Z, ❑ CertilyYJ(' Ia Ie�((� tie <ify inspection division. - FIRE SHRINK ENERGY T 24
APa11111 t "` y r/ MISC.- REFER TO ORD. YE] NE] Y0 NE]
X = CERT114CATF 01'EXEMPTION PROM WORKERSPERMIT ISSUANCE 6.00 FLOOD ZONE- A.L.0 c.
W > COWWHNSATION INSURANCE PLG.CONTR. LIG NO. PLG.
d (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N[_]
Z hundred dollars(S I GO)or less.)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mil is issued,1 shall not employ any person in any manner so as to
t.3 become subject to the Pbrkv,s Compcnvtinn Laws of California.
LU
� CL Dale Applicant4.00 .BUILDING
} W NOTICE '10 APPLICANT: If,after making this Cenificum of Ex- ALTER OR ADD TO MECH. 3 a
? emption,you should become subject to the Workers'Compcosation - APPLIANCE 4.00 PLAN CHECK Z
provisions of the Labor Code, you most forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10)000 C.F.NU .3.00 FEE
CONSTRITC-PION LENDING AGENCY AIR HANDLING UNIT(OVER 10,CMC.F.M.) 5.00 SEISMIC FEE S-D
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Cie.C.). HEATING UNIT(TO 100,000 B.T.U.) 74.00
Lender's Name
Lender's NamAddress 17HEATING UN IT 100,000 B.T.U. .50 ELECTRIC
I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
• information is correct. I agrcr to comply with all city and county PLUMBING
ordinances and stale laws relating to building construulion, and BOILER-COMP 13 H.P.or 100,000 B.T.U.) 4.00
herchy uulhorire mprescntativcs OI This city to cnmr upon the BO
OILER-COMP 10ser 100,000 BTU)SEE FEE SCH.
abovo-memioned pruperty for inspection purpoxs, MECHANICAL
(We) agree to save, indemnify and keep harmless the Cit)'of MISC.- REFER T_O ORD.
Cup it ino agar t habilhisx,judgments, costs and cxpcnxs which PERMIT ISSUANCE .3.00 CONST.TAX
Y Y Y oc nie gen said City in constqucnce of the
gran g I pen L MECH.CONT. LIC.NO. MECH. lZ
ma y.ttp �rJ`` (`.• ?7
TOTAL TOTAL �
Ignal"ura of Apphcam/C[o�nt(rn{'/c/tor Date
OFFICE COPY