17837 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BmIRET APPLICATION &'PERMIT i{�
POORE0 59
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL - N:•y
OWNER'9 ✓1 A, 'O PLAN CHECK VALIDATION
NLME Lyil
OTY. ELECTRIC PERMIT E C N
k.-f�- I PHONE If) �✓ L.f._ I Y V
CONTRA 0y 6��� I-
NAME o�/!!✓ i� `i' Q //��NOUTLETS-SWITCHES-RECEP 10.0 0 0 ' 1
uc.No.
LIGHTING FIXTURES 10.0 Y -r R
CONTRACTOR'S 0 9vf PPLIANCES-RESIDENTIAL 4. � 3� iZy
AD IK,ESS /
�y PHONE (Q PANELS lO. DATE OF APPLICATIOJ
ARC ITECT PLAN CHECK FEE P,C.N
OR PANELS (OVER 200 AMP) _ _20.00
ENGINEER -
Elc.uo. SIGNS TRANS. 3.00
ARCH.OR
SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
ASNrs
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
w o o LICENSED CONTRACTORS DECLARATION
a t 1 hereby off int that 1 ren licensed under provisions of Chapel,9MAY Q -( ISSUANCE DATE
i '
a n (commencing with Section 7000)of Division 3 of Oso Blaine s and BLDG. ELECT. PLG. MECH.
r Professions Code,and my license is in full force and effect.
Z o A - License ClassLic.Number
g m r w Date Contractor City of I:IITIt
a r BUILDING PERMIT
T n OWNER-BUILDER DECLARATION INFORMATION
w ;u y 1 herby aft irm that I am exempt (rent me Contractor's License MISC.- REFER TO ORD
LL_Oa Law forthe followingrwson.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 1000 p VALUATION S/FT.
to Code:Any city oh.or my which structure,
a permit t to is i construct,alter,
(��� V 7
S < 0 improve,Jemulih,or repair any stmc[ure,prior to its issuance,also ELEC.DDNTR. LIC.NO. ELEC.
DLL requires the applicant for such permit to File o signed statement that TOTAL
u is m he is licec.d pursuant to the provisions of the Cm t,c,Ior's License PERMIT TO
rzI Law(Chapter 9(commenhcingwltSection 7000)of Division3of the
Business and Professions Code)or that be is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ Fthe bge
basis for the alled exemption.Any violation of Sect ion 703 t.5 - STORIES TYPE CONSTR.
t� by any applicant for a permit subjects the applicant Ica civil Penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
a
of not mart than five hundred dollars(S500L) V-fsl
❑ Las owner of the property,or my oarl.y"s with wage"as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (See. 7114, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 in z
Coda The Contractor's License Lw docs not apply to 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 or through his own employees.provided that such improve /
meats are not intended or offered for sale.IL however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS-6.00 15b7 CTAK-
or hnprovement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 iiJJ((//
ZIM
builder will have the burden of proving that he did not build ar int- - BUILDING USE
prove for Em,ost of salt.). . RES IND CON PB ' Other
❑. 1,as owner of the pnlpenny,am exclusivelyINDUSTRIAL WASTE INTER. 30.00 contracting with Y ❑ El ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions code:'The Contractor's License Law done not apply •
to an owner al property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractorfs)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the CmUretois License Law. TRACT NO. PARCEL NO.
❑ Iwo exempt under Sm:. ,B.&P.C.for this WATER HEATER W/VENT - 6.00
ms
Owner Dam WATER SYSTEM '. 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSA'IION DFCLARATION WATER TREATING EQUIP. 5.00
I hereby uIfrm that I have a cenificme of consent to slbinmre' ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or v certilleJ
copy thereof(Sec.391)0, b.C.).
Policy No. Cyft,J-yany -
O ❑ Certified copy krchy furnished FIRE SPRINK ENERGY T 24
z Z ❑ Certified ff Is filed with city {pection d''sion.
"ant MISC.- REFER TO ORD. v N Y Q'. N�
O Ap
I- , PERMIT ISSUANCE 10.00 � FLOOD ZONE A.L.U.C.
LU > COMPENSAIION
INSURANCE PLG.CONTR. LIC.NO. PLG. h1 _ � N� YQ NEI
CL Z (This section need not he completed if the Permit i for one TOTAL •JI Y
hundred dollars(S I00)or kssJ
U O 1 certify that in the performance of the work for which this fir- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued, I shall not employ any permn in an,manner so as to
become subject to the Workers'Compensation Laws of California.
� y Dam Appllcanl ALTER OR ADD TO MECH. 500 BUILDING
} to NOTICE TO APPLICANT': If,after making this Ccrm
tifice of lis-
F'? emption,you should become subject to the Worker"Compensation APPLIANCE - 5.00 PLAN CHECK
C..) such provisions r thicas of lor this permit shall be decmcd me Labor Code, you must ock comply well AIR HANDLING UNIT(TO 10,000CF.M.) 4.00 FEE t
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0=C.F.M.) 6.00 SEISMIC FEE gS
I hereby affirm that thee'is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the Ise'mr-mance of the work for which this permit is issued(Sec. MICROFILM 1
3097,Ci,C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender'sNamt H EATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Add. ELECTRIC
lcertify the,l havercadthls application and sine that the a lwvc VENTILATION FAN (SINGLE) 4.00
. information is correct. I agree to comply with all city and county PLUMBING 5'
ordinances And state laws relating to building construction, and BOILER-ODMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby ve- eutioned representatives ins of this city m enter upon the BOILER-COMP (Oser 100,000BTUISEE FEESCH. MECHANICAL 51
above-mentioned prepresY for inspection phi purposes.
(We) agree to s<c indemnify and keep harmless the City of MISC.- - REFER TO ORD. _
uperlino ago' t lis "Pities,judgments, costs end expenses hich PERMIT ISSUANCE -10.00 CONST.TAX ^
may in an Y ccme ., st so City in consquen of th �2 -
rantio It permit MECH.CONT. LIC.NO. MECH,
'I re f ppBcan ontmctor etc G1tf/0 TOTAL / /o.G7
OFFICE COPY l