17814 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY .
BU ILD I NG PROJECT I DENT[FICATI ON PERMIT NUMBER
BUILDING
DRESS tLoT _ APPLICATION & PERMIT 17814.
ADDRESS
i-., i./t (.A L1I� BUILDING - ELECTRICAL-PLUMBING -,MECHANICAL .,
OWNEH'a �NI/ - PLAN CHECK VALIDATION
"aME +1/ F-- QTY. ELECTRIC PERMIT* FEE
TIES PHONE 733 9[v�+•-
NAIaeACTRs UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No. LIGHTING FIXTURES 10:00/1.00
.oPIT ACTOR/ PPLIANCES-RESIDENTIAL 4.00
AD Ess
PHONE PANELS 10.00 DATE OF APPLICATION
ARCH ECT PANELS 200 AMP) 20.00 PLAN CHECK
OR FEE .C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
ZIP EMP.METER OR POLE INS. 20.00
APPLICANT s MOTORS EE FEE SCH.
ADDRESS r
EHA „uJ20.00
woo' LICENSED CONTRACTORS DECLARATIO
a Z w I hereby effuse Ilial I am licensed under provisions 1 to •\� ISSUANCE DATE
(commencing with Section 7000)of Division 3 of theG BL ELECT. P G. MECH.
D z Professions Code,and my license is in full force and effect. •s• y C�•i
z o y - License ClassLie.Number I
Dxtc Contmcmr �`\� ..
a r E BUILDING PERMIT
rt T u OWNER-BUILDER DECLARATION INFORMATION
X
H I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u o Law for the following reason.(Sec.7031.5,Businessand Professions - VALUATION S/FT.
L - Code:An it or count which rerunesa PERMIT ISSUANCE 10.00 (7
YpY Y I Penni toots estmclu alter,
n /y.� r
<Q improve,demolish,or repair any sorudure.Prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. UI �O L 7j VC/Q
O u requires the applicant for such permit to rile a signed statement that TOTAL PERMIT TO ,
E
$ he is licensed pursuant to the provisions of the Contractor's License
H z r LOW(Cha and
rofes co,Ccule) itSection 700xeru p,therefrom
herand
a :he'bess and he alleged
nr ohof he is tion a r echo 70 and DTV. PLUMBING PERMIT FEE S1 VW
Or �'$ 'lice any
a for the alleged exemption.Any violation applicant to a cion malty STORIES TYPE CONSTR.
dam _ by any applicant fora permit dollars thc0),Itoacivil penalty ALTER-DRAIN 5.00
of not more than tido hundred property,
o(my em1: U-�
❑ Las owner of the vile do
II or my.and tires with wages as BACK F LOW PROTECT. DEV ICE 4.00 OCC.GROUP RES.UNITS
inter sole r offered
wdl(S c. work,and the red Pr fi is not
intended or offered for rte(Sec. 7044. Business and n owner r DRAINS-FLOOR,ROOF,AREA,COND. 5.00
CWe:The hContractor's buildsor Limn Law does not apply loan owner of 1
himself
who builds or improves thereon,and who docs improve-
work FIXTURES-PER TRAP 5.00 ser Fr.RLooR AREA ToiaL acREacE
® himself re through his own cmployces,Provided that such improve- _
mems are not intended or olfereJ lot sale.It,however,the building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00 15Q'7 •��� �y,
or improvement is sold within one year of completion, the owner.
GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 CC..JJ RUILOING u5E DO
builder will have the burden of proving that he did not build or im- RES ANO CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER.: 30.00 �/IN ❑
❑ I,as owner of tire
e properly,ant exclusively contracting with
licensed contractors to construct the project(Sec. 70.44,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Prolessions Code:The Contractor's License law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contrathe Cods for su License Law.
Lis wiBlacontranur(s)licensed pursuant,to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's Lien"Law.
❑ I am exempt lender See. ' ,B.&P.C.fur this WATER HEATER W/VENT 6.00
reason
Owner Date - WATER SYSTEM 5.00
• ACC.DATE ACC.FILE NO.
WORK ERS'COMPI'NSA'1'ION DLCLAR ATION WATER TREATING EQUIP. 5.0.0
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers: m
Copensation Insurance.or a certiCwd
copy thereof(See.3800,Lab.C.).
Policy No. Co any '
O ❑ Cerlil led copy rely furnished. FIRE SPRINK ENERGY T-24
❑ Ce 'tied co B filed will the y inspection division
. MISC.- REFER TO ORD.
z'O Appfican Y ❑ NEI Y ❑ N[:]
CC rn CI:R FC1TEOFE.1
FXI T FR Mwr S' PERMIT ISSUANCE 10.00 jd -- FLOOD ZONE A.L.u.c.
W 7 COMPENSATION INSURANCE' PLG.CONTR. - LIC.NO. PLG. ❑ N❑ ❑ NO
O (This section need not be completed if the permit is for one TOTAL Y v
2 hundred dollars(SIND or less.) .
U O 1 certily that in fire performance of tee work for which this per, QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is Mud, I sholl not employ any Parson in any manner w as to
U become subject to the Wnrkcrs'Comper ion Laws of Cal TIMiu.
w Date APPlicanf BUILDING
d ALTER OR ADD TO MECH. 5.00 9. '
} w NOTICE! ye APPLICANT: If,subject
making this Certificate ss Ex-
F 2 pr Ysin,you should nor me Codclbjwt most Wothwit Cco poly with APPLIANCE . 5.00 PLAN CHECK
provision of the Whur it sir you must drevoke pimply with FEE
U such provision or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10pOD C.F.M) 4.00
CONSI'RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=1Z.F.M.) 6.00 SEISMICFEE �.
1 hereby affirm that there is a "instruction lending agdncy lin EXHAUST HOOD (WITH DUCT) 5.00
me performance of the work for which this permit is issued(Sec. - MICROFILM
3097,Civ.C.L HEATING UNIT(TO 11x1,000 B.T.U.) 8.00
Lender's Name HEATING UN IT(OVER 100,000 B.T.U.)9.50 pl �--
hereby
Lender's Address ELECTRIC1 certily Thal I have read this application and'state that theabove VENTILATION FAN (SINGLE) 4.00information is correct.1 agree to comply with all city and county PLUMBING
ofdlru er, and slate laws.relating to building constructionand BOILER-COYvP(3 H.P.cer,100,000 B.T.U.) 6.00 15 authonce representatives of this city to enter upon 0m atwve-mentioned properly for inspection jhupo , BOILER-COMP IOwr tO0,OD0 BTU)SEE FEE SCH. MECHANICAL(We) agree t �.r c, idemnify and keep harmless the City of MISC.- REFER TO ORD.cos, and expenses which CONST.TAXid Cify in coney cote f the PERMIT ISSUANCE 10.00ECH.CONT. LIC.NO. MECH.TOTALTOTAL ,(
etureo ppbcent/Contractor CD/at �I
OFFICE COPY