14401 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION .PERMIT NUMBER
BUILDING APPLICATION & PERMIT A 0 1
ApoREss .� -' e�l - 4 I
BUILDING - ELECTRICAL-PLUMBING MECHANICAL
OwNERs X317
PLAN CHECK VALIDAT
�-� OTY. ELECTRIC PERMIT FEE tf�+ ai►.RaRONE�µ(�-a�7oa a/3 w
NANnERAcr.ns UTLETS-SWITCHES-RECEP 10.00/1.00
o, LIGHTING FIXTURES 10:00/1.00
roNrancroa's PPLIANCES-RESIDENTIAL .4.00
�•
DIRE 31 leyAb 1.-. 1.I .
1 NONE PANELS 10.00 DATE OF APPLICATION
AR HI P� PLAN CHECK FEE P.C.NO.
.--�
OR sq PANELS (OVER 200 AMP) - •20.00
_k SIGNS{ LIC.no.C� 1�. SIGNS TRANS. 3.00
A RCH.OR .0 PERMIT VALIDATION
AOOREss Mer"!• , SPECIAL CIRCUIT 5.00
;Zz• nn,
EMP.METER OR POLE INS. 20.00
APvucA -' MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
Foo LICENSED CONT RACIORS DECLARATION ( ,
a u I hereby affirm that 1 am licensed under provisions of ChapleT 9 ISSUANCE DATE
y < (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
Professions Code,Code,and my license is in full fort'-�p QQQ yyjj((fl.
z o License Iss Lic.Kumtx+..L
9 w H Lice ie; Comr czar IT7r0-\^l ^S
se
OWNER-BUILDER UECLA R,\'TION BUILDING PERMIT
¢ w INFORMATION
w ; n H I hereby allirm that I ons exempt fnnn the Contranur's License MISC.- REFER TO ORD
u O j Law for the following moon.(Sec.7031.5,Busin•xsand Professions LUATION 4/FT.
H - „ PERMIT ISSUANCE 10.00 +
�,� C prove,d city ur coy Ny whiny mrictlae p prior
to c.nsuan e,also 1 �O
¢ IK III
¢ a Q improve,demolish,or repair any slnlctu Te,prior 1.its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O¢ requires the applicant for such permit 1.fie a signed statement that TOTAL PERMIT TO
a w S he is licensed pursuant to the provisions of the Contractor's Limse
H z i
Law(Chapter')leomnluming with Section 70000.1-Division 3ofthe lhl /O.e Off.
E ¢ o Businea and Professions Code)or that he is exempt Therefrom and QTY. PLUMBING PERMIT
¢ the buil(or the alleged exemption.Any violation.(Sermon malty STORIES TYPE CONSTR.
u ; by any morli teal for a permit subjects the applicant toacivil penalty
of not more than five hundred dollars 155001.1: ALTER-DRAIN& VENT-WATER (EA.) 5.00
�-�- ❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 Oce.GROUP RES.UNITS
intended
sole cumpensalion,will do the work,and the strueture a not
intended or offered for sale (Sec. 7044. Business..it Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply In an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO,FT,FLOOR AREA TOTAL ACREAGE
himself.!through his own employees,provided that such improve- GAS-EA.SVSTEM-11NC.40UTLETS 6.00
mends are not intended or offered for sale,IL however,the building
s or improvement is sold within one year of completion, the owner- GAS EASYSTEM OVER 4 IEA) 200
builder will have the burden of proving that h - . - . .
e did not build or lin- BUILDING USE
prove for pa,oscofralc.). INDUSTRIAL WASTE INTER. 30,00 RES IND CON PB Omar
❑ I,as owner of the property,am exclusively contracting with
licensed contractors ors to fine
Contractor's
the project Ln 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.��r^
and owner of Codegrope The Conhuildsr's License Low does not apply ho
to Contracts
owner of h projects
who huilds or Impmvcs rased u,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
tare Co is for such License
wish a conlmclorl s)licensed pursuant To
the Contractor's License law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under See.-,L&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner [)ale WATER SYSTEM 5.00 ACC.DATE ACC.FILENO.
WORK ERS'COSIPENSA'I ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby infirm Th 1 I how u ee Tif f consent to mil-insure. ZONING or c Plical f ke Ep\ n..lir muunce,lcu . ccrlilicd ENG.SITE NO"
C Ii
opy
P.
U ❑ CeniOc yis h m /
❑ Cetlife o fit w 1 e II t Gc'pn divisions - FIRE SPRINK ENERGY T"24
H C- Applicunl L ` t� ; tx MISC.- REFER TO ORD. . Y Q . N❑ Y ❑ NE]
m CERTIFICATE 01:EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE AL.u.C.
LU > COMPENSATION INSURANCE PLG.CONTR, uc.NO. PLG.
CL 0 1'fhis section need not be completed if the permit is for one TOTAL Y❑ NEIY ❑ NE_]
Z h mnd red dol l urs 1S 100)or less.)
U O 1 certify that in the performance of the work for which tMa per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL H mil is issued,1 shall not employ any perwn in any manner so as to
U w become object to the Workers'Compemafion laws of California.
LU Dale APPlicant - BUILDING /f
} w NOl'ICIi"1-0 AYPLIUNI': IL after making this Cenil iealn of Ex- ALTER OR ADD TO MECH. 5.00 2
Z emption,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Codc, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10X0CF.W 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 6.00 SEISMIC FEE 55
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the Ndormance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.0). HEATING UNIT(TO 100,000 B.T.U.) '8.00
Lender's Name
Lcndcri Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this applicaTion and s11de ,,file above VENTILATION FAN (SINGLE) 4,00
information is correct. 1 agree to comply with all city and county PLUMBING
oHimantts and stale laws relating to building construction, and BOILER-COMPQ H.P.or 100,000 B.T.U.) 6.00
herchy a th.rize representatives of this city to enter upon the BOILER-COMP Over 1170,1X10 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purpuscs.
(We) agree t save, in,] and keep harmless the City of MISC.- REFER TO ORD.
ail liabdi judgments, costs and expenses which CONST.TAX
w y ace G s unest said City in c sequcncc of the PERMIT ISSUANCE 10.00
Taal ly1S L 11'. MECH.CONT. LIC.NO. MECH.
00 TOTAL
Sign lum.f App cont/C none r Uale 6-h--_ TOTAL _2� TSS
OFFICE COPY �_