17835 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING. LOT JO G APPLICATION & PERMIT f� r�O/�
ADDREss f Q J J
2O/'_� SIDS I�11 BUILDING >;
=ER'SCL1 w D tp li PLAN CHECK VALIDATION
uAME
PHONE jCITY. ELECTRIC PERMIT FEE
1 ✓� /o���
HAse nc own/" m UTLETS-SWITCHES-RECEP 10.00/1.00
UC.NO. LIGHTING FIXTURES 10.00/1.00
r-onTRAcroR' PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATIO
pN
R "ITEC' - PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LAC.NO. ISIGNS TRANS. 3.00
AARCH,OR DDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
APP
ZIP EMP.METER OR POLE INS. 20.00
ADDCE
IRRESS ss MOTORS SEE FEE SCH. � ..
SERVICE CHANGE PAJQ 20.00
Foo LICENSED CONT'RACIORS DECLARATION
a v 1 hereby aflion that 1 am licensed under provisions of Chaptcr9 I 199U ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
Q a BLDG. ELECT. PLG. MECH.
F N i Professions Code,and nsy license ie in full force and effect `T
z o w License Class - Liu Number
Eric o z H a, Contractor C� Of ( IfP.fI )
a yBUILDING PERMIT
a: Q OWNER-BUILDER DECLARATION
is Q w v INFORMATION
-X o y I hereby uffnn that I con exempt from me Contractor's License - REFER TO ORD
VALUATION S/FT.
F Is Q Law Code:Any city
fng ountreason.hi(Sec.requires
5,Basincosandtocon Professions PERMIT ISSUAN 10.00 12 9
Code:Any city or county which requirese permit toconstruct,,also
0 improve,demolish,or repair any vtruCluro,prior m its issuance,also ELEC.CONTE. LIC.NO. ELEC.
O , requires the applicant for such permit to rile a signed statement that TOTAL LSI TO
w $ he is licensed pursuant to ilia provisions of the Contractor's License PERMIT
F z i Law(Chapter 9(commencing with Section 7000)of Division 3 oflhe qq�-T,',
Q Business and Profasslons Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE Dal Vw -11
¢ r O the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a 3 by any applicant for a hermit subjects the applicant to a civil Penalty ` 1
of not more than five hundred dollars(551X11.): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 1,as owner of the properly,or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole Compensation,will do the work.and the structure is not
mended or offered for sale (Sec. 7054, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 V) f
Code The Contractors License Law does not apply to an owner of T-
• property who builds or improves meson,and who does such work FIXTURES-PER TRAP 5.00 SO,FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employns,provided that such improve-
ments
mprove- q�n
mentsannotintendedoroffered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00 1a-I'YJ4 17AII-,4CO
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 (EA.) 200 BUILDING USE
builder will have the burden of proving that he did not build or ins- . . .
RES ND• CON PB Door,
for purpose of sal.). INDUSTRIAL WASTE INTER. 30.00 ❑ 1:1 ❑ El
1,as owner of the property,am exclusively contracting with
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 improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contrumot6)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ taro exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00 '
Ra 011
Owner - Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSA'I ION DECLARATION WATER TREATING EQUIP. 5.00
I hcrehy uffnn that I have u certificate of consent to sell-inxuc. ZONING ENG.SITE NO.
or a ecUr icatc of Workers' m
Copcnsal ion Insurance,or certified
copy thereof(Sec.JN oc.).
Policy Nn Cnmpuny
Q ❑ Cmliticdc shcrehy lun}shcd.'/� FIRE SPRINK ENERGY T 24
Z Z ❑ Certified py i, Ile J i It air, inspection division. MISE.- REFER TO ORD.Ap nl7if�5f�- ✓ ✓ Y ❑ N❑ V ❑ - N❑
~ PERMIT ISSUANCE 10.00 12
CC y P I11'ICATI:OP : 'IiAf PTION PROM WORKERS' FLOOD ZONE A,L.U.C.,
LU > COMPENSATION INSURANCE PLO.CONTE. LIC.No. PLG. ,f/�
CL 1'Fhis section naedl not he completed if the permit is for one TOT
Y❑ N❑ Y ❑ N❑
Z hundred dollars(5100)or lm.) .
U O I certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL Umit is issued,1 shall not employ any person in any manner w as to
become subject to the W'orkcrs'Compensation Laws of California s
U i Dmc - Applicv'I ALTER OR ADD TO MECH. 5.00 BUILDING 1-
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z emption,YOU should become subject to the Workers'Compensation APPLIANCE5.00 PLAN CHECK
provisions of the Labor Code. you must forthwith comply with a FEE --
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT.(TO 10,10MC.F.NL) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10DMC.F.M.) 6.00 SEISMIC FEE SJ✓
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 HEATING UN IT(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 d
S information is correc4l agree to comply with all city and count)' PLUMBING 4]]
ordinances and state laws relating to building construction, and BOILER-COW(3 H.P.or 100,000 B.T.U.) 6.00 �-///I]
hcrehy xathoride represamat ivos nl the city to anter upon the BOILER-COMP (Over 100,000BTUISEEFEESCH. MECHANICAL `rl
above menlI ned pro arty for inspection purposes.
(W a) agree t indemnify and keep harmless the City.1 Misc.- REFER TO ORD. -
uperhno
all
t Ifabilitics,judgments, costs and expanses which PERMIT ISSUANCE 1000 Q _ CONST.TAX �a- - 7
coy in any uccryc akui said I in conutquan of t c _
doling u s peno t ECM.CONT. LIC.NO. MECH.
` Q TOTAL �9b� TOTAL
[ edr 11
74
APPicent/ on cLLsr to r2
OFFICE COPY
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