09676 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES _ USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FI CATIO PERMIT NUMBER
BLILG,NGAPPLICATION & PERMIT
A°°R � 09676
BUILDING —ELECTRICAL—PLUMBING —MECHANICAL
OPLAN CHECK VALIDATION
NFE CITY. ELECTRIC PERMIT' FEE
•/ PHONE
NOMrRAcroRs UTLETS-SWITCHES-RECEP 10.00/1.00
III sec.no.- / LIGHTING FIXTURES 10.00/1.00
/ r-ONrR�/���J/roRsQ PPLIANCES-RESIDENTIAL 4.00
"1C AO° (q8 PHON — 7 PANELS 10.00 DATE OF APPLICATION
/ AARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
on
ENGINEER
LIC,NO. SIGNS TRANS. 3.00
ADDRESS EN SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP p
EMP. METER OR POLE INS. 20.00 pit
APPLICANTS
ADDRESS MOTORS SEE FEE SCH. e
DRESS Ess @@ Q J
SERVICE CHANGE 20.00 SEP
U 196
¢ TEMP.POLE 90.00 Dmtr1
o o
LICENSED CONTRACTORS DECLARATION p jF �kra.I's
< u v I hereby affirm that I am licensed under provisions of Chapter 9 — yl A� ATE~O
Nz (commencing with Section 7000)of Division 3 of the Businessand
QBLDG. ELECT. PLG. ME H.
o z Poofessmns Cod and y license is in full furca and ec _
o Z' a Licen lass C.,ractor ❑ ❑ ❑
Uate ;_Contactor
a x L in
BUILDING PERMIT
¢ ¢ 6 a OWNIi R-BUILDF;R DECLARATION INFORMATION
X
y 1 hereby affirm that 1 am exempt from the Contractor's License MISC.— REFER TO ORD
H ..
U. Law for the followinSrcason.(Sec.7031.5,Businessand Profeadons PERMIT ISSUANCE 1000 VALUATION S/FT.
,Aft Code:Anycity orcounty which requiresa permit to construct,alter,
¢
400,
Q improve,demolish,or repair any structure,prior to its issuance,aLw ELEC.CONTR. LIC.NO, ELEC.
o¢ requires the dp pursuant
fur such permit to ole a signet statement that TOTAL eco DITTO
w $ u, he is(Chapter
licensed 9(comm to the provisions of the Cont Division
License rM"'(VVI/l//-!,ly
H 2 r Law(Chapter9(commencine with Section 7000)of Divuion3of the
Q Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT _ FEE
¢ F the basis for the ul lcgcd exent ption.Any violation of Suction 7031,5 - STORIES TYPE CONSTR.
n ; by any applicant for a permit subjects the apppli .) 5.00
cant to a civil penalty ALTER-DRAIN&VENT-WATER (EA
of not mart than Five hundred dollars(S500)): '
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not _
intended of offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Cale:The Contractor's License Law don not apply to An owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 Sa FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such intprove-
meatsarenat intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING DUSE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 3000 — 5 IND CON PB One, •
❑ I,as owner of the prop .
property,am CAClusivcly contracting with / El , 1:10 ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improve thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contmetons)licensed pursuant to
the Contractors License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sea.—,B.&P.C.for this WATER HEATER W/VENT ' 6.00 r
reason
Owner Uwe WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARA'T'ION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent m self-insure. ZONING
or cenificate of Workers'Com Penswi o 1 wance,or a certified ENG.SITE NO.
copy
them p�{, 0�I�b C.1. ��� �/"'J,
Policy NaPiL faitSpao urno L—U
IieJ copy she y lurm;lw
Z = ❑ rliu mi ed w' th inspecYo Division. FIRE SPRINK ENERGY TYa
O Applicant MISC.- REFER TO ORD. Y N❑ Y ❑ N❑
QN
CR I 4d A'rE Oi6� ' 10 -ROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
LU COMPENSATION INSURANCE PLG.CONTH. LIC.NO. PLG.
CL Z (Thu section need not be Completed if the permit is for one TOTAL Y[:] N❑ Y❑ N[] ,
hundred dollars IS 100)or IessJ
U O 1 certify that in Ota performance of the workfor which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued,1 shall not employ any person in any mannerso as to
O w become subject to the Worker Compensation Laws of California.
n Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
2 emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
CJ oath provisions or this Permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M) 4.00
CONSTRUCTION LENDING AGE AIR HANDLING UNfTIOVER t0,000GF.M.16.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) &DO
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address 'ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
.� inforinmation is correct.I agree to comply with all city and county PLUMBING
ordances unit state Jews relating to building construction, and BOILER-COMP I3 H.P.or 100,000 B.T.U.1 6.00
hereby authorize representatives of Use city to enter upon,the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH.
rpo
abon-mentioned property for inspection Puses. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- - REFER TO ORD.
CuperC o 'est Bahilitics,judstncnts, Costs and uAPcnses which •pERMIT ISSUANCE 10,00 CONST.TAX
y i an ay accrue ag id City in consequence of the
gra this i1, MECH.CONT. LION MECH.
r� f r �S TOTAL e. TOTAL (L
Si tat ¢of APP t ntruc ser Data J 1/V
OFFICE COPY