17828 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
,PERMIT NUMBER _
BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT v
emlDmc '"j 2� E3 17828
A Ess
'1 �1 UILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'5 ' A 1 IDN A PLAN CHECK VALIDATION
NAME IJJ."s fCLr-+ FFfTTT��ZZ(]/�/I Y. ELECTRIC PERMIT FEE
• E
PHONE JW"I-
CONTRA
NAME f�//ZN/"a7� OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC,NO, LIGHTING FIXTURES 10.00/1.00
coNTRPCToey/G D
ADDEs p G' APPLIANCES-RESIDENTIAL 4.00
PRONE PANELS 10,00 DATE OF APPLICATION
ORCI ECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE .C.NO.
ENGINEER
- uc.NO. SIGNS TRANS. 3.00
rADD 'Ess ENa SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH. 1
ADDRESS
SERVICE CHANGE FAM, 20.00 TIA J
oo -LICENSED CONI'RACTOR9 DECLARATION 3,1!D Li`
v I hereby affirm Thal I am bcemcd under provisions of Chapter 9 MAY I U ISSUANCE DATE
zw (commencing with Section 7000)of Division 3 of the Business and
G 4 ° BLOG. ELECT. PLG. MECH.
F N z Professions Code,and my license is intuit force and effect. Ip7 ISI
o 0 v, p Lice e,e ClassLic.Number I O .ROP. iQ� bl �-
Date Contractor
a m f - BUILDING PERMIT
¢ ¢ 4 OWNER-BUILDER DECLARATION
A o=" I - FER TO ORD INFORMATION
X 3 s-st, ,I hereby affirm that 1 am exempt from the Contractors Licen.
u O j Law for the following reason.(See 7031.5,Businessand Pm&ssio A C 10,00 I`� _ VALUATION S/FT.
~ wi Cade Any city or coumy which rcquir�apemlit toconstma.altc q'
¢ ¢ 4 O inmrove,demolish,or repair any structure,prior to its issuance,also LE O Q �O IC.NO. ELEC &
tc wO LL requires the applicant for such permit to Ok a signed statement that O� l TOTAL 51 PERMIT TO
las is licensed pursuant to the provisions of the Contractor's License _
F z a Law(Chapter 9(commencing with Section 7000)of Division 3 of Inc SF-Dkll,
Business and Professions Code)or tout he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
w. by any applicant for a permit subjects the applicant to a civil penally
OI of ALTER-DRAIN& VENT-WATER (EA.) 5.00 v_L.{
nmore than live hundred dollars 15500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,unit the structure is not OCG.GROUP RES.UNITS
intended or Offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 K-3 }
Code:The Contractors License Law does not apply to on owner of 1
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve- .
ments are not intended or offered for sale.l f.however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00 I �(�� �Ap�M
or Improvement I is sold within one year of completion,the owner- GAS-EA.SYSTEM OVER 4 (EA) 200 ei `fE--L--J
builder will hove the burden of proving that h - . .
e did not build or im_ .BUILDING USE
prove for purpose of saleJ. INDUSTRIAL WASTE INTER. 30.00 RES CON PB Omit,
❑ I,as owner of the property,um exclusively contouring with L7 El El
El El
licensed contractors to construct the project(Sec. 7044.Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 Ass ESSORSPARCELNO.
and Professions Code'fhe Contractor's License Law does not apply
to an owner of property who builds or improves thercon.and who LAWN'SPRINKLERS-OVER 5 (EA.) 1.00
conthe Comsforsu License
Lwirhacommetods)licensed pursuant to SEWER-SANITARY-STORM EA.200tt/10.00 - TRACT No. PARCEL NO,
thel omranor's License Law.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT' 6.00
reason
Osvncr Date WATER SYSTEM 5.00 ACC.OATE ACC FILE NO.
WORK 6RS'COMI'ENSATION Dd*CLARATION WATER TREATING EQUIP. 5.00
I hereby uffmt Her 1 have a ecriflLale of consent Io wiLinsine. ( _ ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof"C",
38 LathC I
Policy No. - pony
O ❑ Certiliedc0 hereby furnished FIRE SPRINK ENERGY T.74
FZ" O A❑ 4a suited is lilctl with tl c ci inipcaiun ivision. MISC.- RE7TOTAL
TO ORD. v N v N
H PERMIT ISSUANCE 10.00 r� ❑ O ❑ ❑
.CC - 'IFICATP.OFIi%li PT 'FRO; WORKIiRS' �/� FLOOD ZONE -A.L.U.C.
Ud 1 COMPFNSATION INSURANCE PLG.CONTR. LIC,NO. PLG. _ (p V N Y N
CL Z 1'[his senion need not be Completed if the permit is Ibr one :J _
hundred dollars(S 100)or IC,I r,
U O 1 certify that in the perfornwnce Of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL F mil is ued,1 shall not employ any person in any manner so as to
C) W hCCOIRO subjecti to the WorkerConlpensution Laws of California.
O_ Date-Applicant - ALTER OR ADD TO MECH. 5.DO BUILDING 1-I 7,/
} N NOTICE TO APPLICANT: If,alter nm king this Cerificam of Ex- ✓ t
? eruption,you should become subject to the Workers'Compeosation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code,you most forthwith Comply wilb FEE �-
U such provisions or this permit sall be deemed revoked AIR HANDLING UNIT(TO 10=CF.M.) 4.00
CONSTRUCT ION Ll'NDING AGENCY AIR HANDLING UNITIOVER 10=C.RM.) 6.00 SEISMIC FEE
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 Noma HEATING UN IT 100,000 B.T.U.)9.50 51
Lender's Address ELECTRIC
I C
I certify that 1 hove read this application and stun that the above VENTILATION FAN (SINGLE) 4.00
information is Estateagree
. I agreto comply with all city cti county PLUMBING I ��
ordinances and store lows tc to building construction, and BOILER-CCMaPO H.P.or 100,000 B.T.U.) 6.00
hereby authOr7C TxjRCSenLtives Of this city W enter upon the BOILER-COMP (0ver100,00OBTUISEEFEESCH. MECHANICAL 5I (06
above nsemim:d is arty for inspection porm,V,'.
(We) agree
tyle e, indemnity and keep harmless the City of MISC.- REFER TO ORD- ,� - ^ //�
up tion, a s abilities,just n13, costs and expenses which PERMIT ISSUANCE 10,00 CONST.TAX d s W
nay in an accm gain 'id In consequ ce o the !!
ntIng ss Perini MECH.CONT. LIC.NO. MECH.
TOTAL Lit 13 TOTAL 1J'10.67
aloft of Apel ant/Contractor Umc '
OFFICE COPY