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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON
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APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PER IT N
245
BUILDING
AO REss �r�-lC
' O
OWNER'
"7E
_
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
/ [J vHONE
DATE OF APPLICATION
CONTRACTORS
N ME E�T L
r-h,A Rear C LIC. ND.i 637
51 OUTLETS - SWITCHES -RECEP 5.00/1.00 yii-Dp
LIGHTING FIXTURES 5.00/1.00 Da- If)
OOD CTORs
ADDR
C f)'''''
�_1 `' CVe-I ONE of ,S-
- RESIDENTIAL 4.00
APPLIANCES5'51
PANELS 5.00
ORRCH]TECT -
ENGINEER
LIC. NO.
SIGNS 6.00
PLAN CHECK FEE
.C. NO.
SIGNS TRANS. 3.00
ADDRESS eea
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 15.00 '
zIP
`�/r( j
'S
AD ADDRESS
ADDRESS
E -vel
MOTORS S E FEE SCH.
SERVICE CHANGE 10.00
LICENSED CON TR ACTORS DECLARAI'[ON
- MAR 14.
I hereby affirm that I Sun licensed under provisions of Chapter
(commencing with Section 7000) of Division 3 of the Business and
Professions Cod •, anJ license is in full fort • nd 1 •
_r "� Y
Lic. Number
ISSUANCE DATE
city ,.L ls6nehin
BLDG.
❑
ELECT.
PLG. MECH.
❑ ❑
Dcens�Cla�s
Date d-//�� Cnntmctor _2�Pr;
.
K
OWN 1. R -BUILDER DELLA RA'T'ION
I Hereby affirm that I em exempt from the Contractor's License
law for the following rexsoo.(Scc. 7031.5. BuRnessand Poa(cssurs
Code. Any city or county which requires a permit to construct. alter,
BUILDING PERMIT
INFORMATION
-
MISC. - REFER TO ORD
PERMIT ISSUANCE 6'� �'UD
VALUATION
S/FT.
ELEC. CONTR. LIQ N0.
C�'FPaG
ELEC
TOTALW. 00
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant To the provisions of the Contractor's License
(Chapter 9(commcncing with Section 7000) of Division 3 of the
Business and Prolusions Code) or that he is exempt therefrom and
PERMIT TO
4_(�-e-7 �Ie 9,
QTY. PLUMBING PERMIT FEE
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of net more than five hundred dollars 1 S500L)T
STORIES
TYPE CONSTR.
ALTER -DRAIN (EA.)
O 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 2.00
oee. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 4-00
intended or offered for sale (Sec. 7044, Business and Professions
Cede: 'Fhe Contractor's License law does not apply to an owner of
FIXTURES - PER TRAP 4.00
property who builds or improves thereon, and who does wdl work
himself re through de own employees, provided that such improve-
memsarrnor throuwndedornffered ces,or proondeowevegthcmprAng
SO. FT. FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM -1INC. 4OUTLETS 4.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build for ma -
prove for pur,oseofxale.).
❑ I, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 1.00
BUILDING USE
RES IND CON PB Dime,
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
licensed contractors to construe the projeci (Scc. 71144, Business
and Professions Cache: I he Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
ASSESSORS PARCEL NO.
LAWN SPRINKLERS'- OVER 5 (EA.) 1.00
contracts for such projects with a contralorts) licensed pursuant to
the Contractor's License Law,
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCELNO.
ReB ❑ I an, exempt under Sec. , ELAP,C. for this
son
WATER HEATER W/VENT 4.00
Det, Owner
WATER SYSTEM 4.00
ACC. DATE
ACC FILE ND.
WATER TREATING EQUIP. 4.00
wORKI:RSCOMPI:NSA'NON DECLARATION
I hereby affirm final I have a certificate of consem to sell -insure,
or a certificate of Worker' Compcnmlinn Insurance, or u certified
ZONING
ENG. SITE NO.
copy thereof (Sec. 3800, Lab, C. 1sla'di n TnSIX'�aCQ CO•
Policy No. Company
%H6 f-
divi�FIRE
X ❑ Certified copy is hereby furnished. N
Ilcd city ns,cllon 11
ASFlca
SPRINK
Y❑ - N❑
ENERGY T"24Cerl
Y❑ NEI
MISC.- REFER TO ORD.
CF RI FICA 113 OF EXEMPTION FROM WOR KERS*
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.U.C.
CONIPFNSATION INSURANCE
(Phis section need not he Sun, pleled If the permit is for one
Y❑ N❑
V❑' N❑
PLG. CONTR. LIC. NO.
JPEG
TOTAL
hundred dollars(SIO0) or less.)
I certify that in fife lwrfurnuna of the work for which thrs per-
mit is issued. I shall not employ any person in any manner so as to
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
,
become wbjca [I, the Workcn' Compen.wtion Laws al Calitbuua.
ALTER OR ADD TO MECH. 4.00
Date Applicant
BUILDING
NO] ICE TO APPLICANT: If, He, making this Certificate of Ex-
APPLIANCE - 4.00
PLAN CHECK
FEE
emption, you should become Subject to the Workers'Compensation
provisions of the labor Code, you must forthwith comply with
such provisions or this permit shall he dcaned revoked.
AIR HANDLING UNIT (TO 10SWCFJVL) 3.00
AIR HANDLING UNIT (OVER IOAOOC.EM.) 5.00
SEISMIC FEE
CONSTRUCT ION LENDING AGENCY
" I hereby a(finn that them is r construction lending agency fur
the performance of the work for which this permit is issued (Scc.,
3097. Civ.C.).
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address
HEATING UNIT (OVER 100,000 B.T.U.P.50
A
-ELECTRIC
0
7
Icertify Hurt l hove reed this application and state that the above
VENTILATION FAN (SINGLE) 3.00
information
information n correct. I agree to comply with all city and county
ecu and slaw .I a meting to building construction, and
PLUMBING
BOILER - COMP I3 H.P. or 100,0000.T. U.1 4.00
BOILER-COMP(Over 100000 BTU) SEE FEE SCH.
MECHANICAL
hereby
mentioned property far sm of
above- authorize roperty for in of this city e, cater ulrlm the
puity 1.,
(We) agree to save, indemnify and keep harmuss The Ci(y of
MISC. - REFER TO ORD.
Cufx•rti to against liahilitiu, judgnlems, Costs and expenses which
m m any way accrue against said (-'yin consequence of the
- PERMIT ISSUANCE 300
CONST. TAX
g nl)ng of this permit
U n?_
23
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
atrlrenf ApplicunH/Contruetor ate
OFFICE COPY