17818 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY 1'
BUI LDI NG PROJECT I DENTI FICATION PERMIT NUMBER
81-ill-DING
n APPLICATION & PERMIT -
. OAWo�NE�R'S� nBUILDING
.
-ELECTRICAL-PLUMBING-MECHANICA
L _• n
818
PLAN CHECK VALIDATION
NA EE [_Alp TY. ELECTRIC PERMIT FEE
yHONE-T5J-%. UTLETS-SWITCHES-RECEP .10.00/1.00; /� �
LIC No. ,� LIGHTING FIXTURES 10.00/1.00
r-DNTRACTORs 1,,D � ^ PPLIANCES-RESIDENTIAL 4.00
OHE55
PHONE '` PANELS 10.00 DATE OF APPLICATION -
ARCATECT I P ANELS (OVER 200 AMP) 20,00 PLAN CHECK FEEP.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTSDDRESMOTORS SEE FEE SCH.
A .
SERVIC H NGE 20.00p�-,�..f���.\���-�+�r+��-(�
w O o LICENSED COXI'RACTORS DEC A I fI
A U w 1 hereby affirm that Iain Iicensid under pro]' C pt t ISSUANCE DATE
(commencing with Section 70001 of Division�A1hf�Hsi - G BLO ELECT. PLG. MECH.
F m z Professions Cole,unJ my license is in lull liuc■W_I_�•c'{Ifyf C l�
z o m License Class Lia Number [.C�I' r1E�'
o N F w Dare Contractor
¢ m f , BUILDING PERMIT
¢ In ¢ OWNER-BUILDER'DECLARATION C( of Clmertin
p: w u INFORMATION
X
e- w I hereby aftinn that 1 am exempt from the Contractor's License MISC.- -REFER TO ORD
LL o v, Law for the following reaysn.(Sec.]031.5,Rosiness unJ Professions VALUATION $ET.
_ PERMIT ISSUANCE 10.00 'J, - )
Code:Any city or county which rer,cuesa permit tocontDomaller,
rt ¢Q20 improve,demolish,or repair any structure,prior mitrissumtt,also ELEC.CONTR, LIC.NO, ELEC.
O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
IL
he is licensed mi...sent to thN
e provisions of the Comcloi s License
A.
HiQ Law.(Chapter 9 fcommencing with Section 7000)of Division3 ofde
i D Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
Iz H $ the basis for the alleged exemption.Any violation of5ection 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars(5500).1: 'ALTER-DRAIN&VENT-WATER (EA.) 5.00 V-
❑ 1;as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 Doc.GROUP RES.UNITS
their sole compensation,will do the work,and the structure n not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CONIC. 5.00 VI_7� I
Code:The Contractor's License Law does not apply to an owner of f�
property who builds Or Ilttpnw.thereon,and who does such work F IXTUR ES-PER TRAP 5.00 66 FT.FLOOR AREA TOTg�ACREAGE
• himself or through his own em Ployc s.provided that such improve- A
mmvs are not intended or offered.for sale.I L however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00 _ �,�.3�
or improvement is sold witim one year of completion, the owner- GAS EASYSTEM OVER 4 IEA.) 200
builder will have the burden of proving that he did not build or int - . - . .
- BUILDING USE
prove for purpose of sale.). RES IND CON PB Orhar
❑ I,as owner of the property, y contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑
pn ons project
(S licensed contractors to construct.ContracThetor project(Sec. ]044,of Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
an it Professions Codegrope The Contractor's o Lobos Law Joel not apply
to lir owner of property who builds or improves used p,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
Contracts far such ceneprojects with v contracioR sl licensed punuant m
the Contraemr's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
O I am exempt under Sec. ,B.R P.C.for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM - 5.00 ACC.DATE ACC.FILE NO.
. WORK ERS'COMPEN'SATION DECIARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate ofemasent to WIF-insure. 3 i ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy the,cof(Sec.3800,Lah,C.). -
Poncy No. Coo any
O ❑ Certifledcopy' rehy furnished RE SPgINK ENERGY TBO
Z p A01mcC,nificd ao a filed,wi the 'ry'inspecf bn division. MISC.- REFER TO ORD. Y N Y N
❑ ❑ ❑ ❑
ir y CERT JCA'IT of:I: , TI PROMROM WO PERMIT ISSUANCE 10.00 i2FFLOOD ZONE A.L.0 c.
EU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. I.G.P
CL
Z This section eed not be completed if the permit is for one TOTAL 1 Y❑ N❑ Y [:] N❑
hundred dollars IS 100)or lm.) -
U O 1 certify that In the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL I- nut is issued,I ,all not employ any person in any manner so as to
O W bcerwe subject to the Workers'Conmpenmfion Laws of California.
Date AppllcaN BUILDING O�
a ALTER OR ADD TO MECH. 5.00 rTUo-' r
} to NOTICE TO APPLICANT: If,after making this Certificate of fix
Z emption,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MOC.F.ML) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE �✓'�
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the perforrnar" of the work for which this permit it issued(Sec. MICROFILM -�
3097,Cie C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's.Na
Addr HEATING UNIT(OVER 100,1X)0 B.T.U.)9.50 <J
Lender's Address ELECTRIC LEq
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
S informationis correct.1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-CCAV(3H.P.or 1DOXOB.T.U.) 6.00 Dr
hereby authorize representatives of this city to enter upon the Vef , . MECHANICAL
alwve-mentioned property for inspection purposes. BOILER-COMP IO100000 BTU)SEE FEE SCHE
(We) a¢reC t ve. indemnify and keep harmless the City'of MISC.- REFER TO ORD. 3 f H
aperRno a 'liabilities,judgments,costs and egpenses which PERMIT ISSUANCE 1000 12 CONST.TAX
�glin,
an y ace )agai 1 said Cit N cons: •Ace of the
PerM ./ MECH.CONT. LIC.NO. MECH.
TorALTOTAL 174,
App lice t/ ontractor Date
OFFICE COPY