17840 APPLICANT TO FILL IN INFORMATION,WITHIN RED LINES - USE'BALL POINT PEN ONLY
BU LOI NG PROJECT I DENT[F[CATION PERMIT NUMBER
BUILDING r 3 APPLICATION & PERMIT
ADDRESS _ 17840
2DZ4,/'_ JI G11 DING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'SL /,ND 1`4/ PLAN CHECK VALIDATION
NAME L�'�I`�
® -n OTV. ELECTRIC PERMIT FEE
�y /1.�1� vHONE �
NArM>ER" Too �//)2y /✓y// (/ OUTLETS-SWITCHES-RECEP 10.00/1.00
O� uc NO. LIGHTING FIXTURES 10.00/1.00 - -
corvTRAcaaR ��O PPLIANCES-RESIDENTIAL 4.00
ADDRE64/1
PHONE PANELS 10.00 DATE OF APPLICATION
ORCHI CT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C`,
ENGINEER
LIc.No. SIGNS TRANS. 3.00
ARCH.Ess ENO' SPECIALCIRCUIT 5.00 PERMIT VALIDATION,
ZIP TEMP.METER OR POLE INS. - 20.00
APPLICANTS MOTORS- SEE FEE SCH. qq
AODRESS W
I
SERVICE CHANGE 20.00 ^h-�i3rlfL. R
or
F o o LICENSED tCONI
Ian, CTORS DECLARATION A
a v w 1 hereby a(finn [hal 1 um licensed under provisions of m tr�! ISSUANCE DATE
yz (commencing with Section 7000)of Division 3 of the Busm ss an
Z, y 1QU 1 BLDG. ELECT. PLG. ECH.
H N z Professions Calc,and my license is in(all force and effect. Dki 011 J Y0�'(.'f(
o In - License Claus Lic.Number -
F w r Date Contractor - r
F
x f < Z2. BUILDING PERMIT
¢ ¢ w¢ OWNER-BUILDER DECLARATION f CIIOP.rt1BO
a o a DA _ EFER TO ORD INFORMATION
w 3 I hereby affirm thm I um exempt fans the Contr .License - VALUATION SIFT.
FLLoa Law For the following reason(Sec.703 L5.Iiusinessand Professions PERMIT ISSUANCE 10.00
Code Any modish county whiny structure perms o its i suanc ,also T 51� (��r 1.1-E--�
xor Q improve,demolish,or repair any structure.prior ID its issuance,also ELEC.CONTR. LIC.NO. ELEC.
0 LL requires the applicant lot such pennit to file a signed Statement that TOTAL PERMIT TO
wm he is licensed punuanl to The provisions of the Contractor's Liwnse '
F z i
Law(Chapter 9(commencingwith Section 7000)of Division3 of ilio S�fll1 L
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT . FEE
¢ = the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a � by any applicant for a permit subjects the applicant to a civil penaly 00) 5.
of nor more than five hundred dollars(S500r): ALTER-DRAIN& VENT-WATER (EA.
❑ 1,as owner of the property,or my employres with wages as BACK FLOW PROTECT.DEVICE 4.00 CCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sc, 7614;Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 i7 'Z. I
Code:The Contractor's License,Law docs not upPly to an owner of F__
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT FLOOR AREA TOTAL ACREAGE
• himself or through his own employees.Provided that such inl(!nwe- Fp-7
meats are not intended or offered l'ur sale.If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00 ('JP l '
ides will
mem is e b within one year of hacompletion.the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 -/BUILDING USE
builder will have the burden of proving that ht did not h he or"
prove for purpose of sale). RES IND CON PB Other
❑ I,as owner of the property,um exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 m/ ❑ ❑ ❑ ❑
licensed contractors In construct the project(Sec.7044,Intones, - LAWN SPRINKLERS-1 INC 5 V.B: 6.00 LAS As ESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 -
contracts for such projects with a conlractons)licensed punuunt to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,- B,&P,C.for this WATER HEATER W/VENT 6.00
reams
Owner Dale WATER SYSTEM .5.00 I ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
hereby
1 affirm that I have a cenifcare of ennsent In self-insure. ZONING
or a ee NiRcme of Workers'Compensation Insumnee,or 3 certified ENG.SITE NO.
copy thereof(Sec.3800,1,tf l.).
Policy No. C9AIp ny
O ❑ Certified copy.�Kchy(.to is / FIRE SPRINK ENERGY T 24
❑ Certified co s filed 'wit in y' inspection division. MISC.- REFER TO ORD.
Fp APPI' nl � _ Y ❑ N Y ❑ N❑
va PERMIT ISSUANCE 10.00 q
LU - CA ICA IS OP SAT[ 1 NPR M WURKIi RS' Z. FLOOD ZONE A.L.U.C.
W � COMPENSATION INSURANCE, � PLG.CONTR. LIC.NO. PLG.
CL 0 CL Z (Phis section need not be completed if the Permit is for one TOTAL 51 ,Cob Y❑ N❑ Y❑ N❑
hundred dollars(S 100)or kat)
U O_ 1 certify that in the perfommmc of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
W I- mit is s�ucd, I shall not employ m any peryin any manner so as to
U hecmne subject to the Workeri Compensation Laws o1 California. -
III Doe Applicant BUILDING �-f A77.7
>_ 0NOTICE 1'0 APPLICANT: If,after making this Cerlificahe of F,x- ALTER OR ADD TO MECH. 5.00
? camption,you should become subject to the Workeri Compcnsalion APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Coda you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) - 4.00
CONSTRUCTION LENDING AGENCY . AIR HANDLING UNIT(OVER 10,000C.EM.) 6.00 SEISMIC FEE aa�
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) -.5.00
the Performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATI NG UN IT 100,000 B.T.U.)9.50 S1 bg
Lender's Address ELECTRIC
1 certify that 1 have read INS application and swte elm,the above VENTILATION AN (SINGLE) 4.00 I
information is correct. I agr c to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-OCW"F(3H.P.or100,000B.T.U.) 6.00
hereby author, representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
aMrve-mentioned pr crty forinspection purposes. -
(Wc) agree I m c, indemnify and keep harmless the the City of MISC.- REFER TO ORD. ^
upetlino ag ' s�fiahilitics,judynenu, costs and expenses which - PERMIT ISSUANCE 10.00 CONST.TAX
IT in an accrue in id City inconsoq ce of he
slI ng permit. / ` MECH.CONT. LIC.NO. TOTAL ' TOTAL
/O•/` /n y/
lure of Applicant C ntracmr Ume 51 �$ /
OFFICE COPY