17824 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT „ . 17824
ADDRESS
/DURESS {{��__
�GYO 51 u11� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL p
OWNER'S PLAN CHECK VALIDATION
NAME t-1�Nfl t�1� �s 'I CITY. ELECTRIC PERMIT FEE
TICS. PRONE ITJ7j 64-5 -
CONTRAc 0NNAME / OUTLETS-SWITCHES-RECEP 10:00(1.00
IJ//
LID.No, LIGHTING FIXTURES 10. /1.00 -
CONTRACTOR
ADDREss / PPLIANCES-RESIDENTIAL 4.00
/R
V /l
ONE PANELS y/ 10:
J (� \`y GATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
oR PANELS (O ER 200,AMP) ( - _
ENGINEER
sec.No. SIGNS TRAS. 3.00
ADRC .011DRESS ENG. SPECIAL C.I f., IT rJ PERMIT VALIDATION
zm TEMP. METE ORP LE INJ.117 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADORES
SERVICE CHANGE 20.130 l^!t-1�- T�}t
o o LICENSED CON'1'RACfORS DECLARATION D V FFv.T,"V -
¢ is I hereby affirm that I am licensed under provisions TChepler 9 111 ISSUANCE DATE _
z w (commencing with Section 7000)of Division 3 of the Business and
[� I I, BLDG. ELECT. PLG. MECH.
H z Li,,.sio laCode,and my license is in full force and effect.
zits Licenu Clan his.Number -
0 n r W DaIC Contract Ur
¢ y a City of PlInoM_jn/l BUILDING PERMIT
M ¢ w< OWNER-BUILDER DECLARATION INFORMATION
X
A w I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u O J Law for file following reason(See.7031.5,Ifiuineasand Professions VALUATION - $/FT.
r - Code:Any city oreoemty wllicbraluiresa Nrinitioconstruct,alter, PERMIT ISSUANCE 10.00 I2/'Q- /]•� /-� 0
rtQ < p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. COO
requires the applicant for such pnnnit to file a signed statement that TOTAL rj- •� PERMIT TO
a- ZLL me
he is liced pursunl to the Provisions of the Contractors se
Licen
.azo Luw(Chapter 9(commencing witll Sectim17000)a f Division 3ofthe Q�1'l,ll
¢ Business and Professions Code)or that lie is exempt therefrom and OTY. PLUMBING PERMIT FEE
re r D the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. .
by any applies,,(fora permit subjects thespplicant too civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five peon and dollars 15500).1: V
❑ 1,as owner of The properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the stmcturt,is not
intended or Offered for Ale (Sec. 7044. Business unit Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code: The Contractor's License Law dos not apply to an owner of 'Y2__311
m property who builds or improves thereon,and who due3 such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL A/C�RE�AyGE�
himself re through his own employees.Provided that such improve-
memsarenotimmndedorofferedforsalelLhowever,the building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00 IG0> CT<`�
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 :J BUILDING USE
ha ll will have the burden Of proving Thal he did not build orim RES IND CON PB Other
prove for purpose of sale J. INDUSTRIAL WASTE INTER. 30.00 t-EI�
❑ L as owner of the property,am exclusively contracting with LJr ❑ ❑ ❑ ❑
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 huilds or improves thcrcon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts fursuch projects whll a contructana)licensed Plmuanl to
the Contractor's License Law, SEWER-SAN ITARV-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
O l am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
Tolson
Owner Dale WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSA'I'[ON DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a cc ificule ntconsent to self-insure. ZONING ENG.SITE NO.
Or a cerlif¢ale Of Workers Compensation Insumnee,or a certified
ropy thereot(See.3800,1 .).
Policy No. Co
0 ❑ Ccrlilicd copy N)(Vrirby turm,hed. FIRE SPRINK ENERGY T 24
Z O A1❑ Cnrlilled cop filed with' t ily penin_ - n d °". MISC.- REFER TO ORD. Y N v N
❑ ❑ ❑ ❑
CC
w CI: T4- ATE OPI xEm ONF OM WORK ERS' PERMIT ISSUANCE 10.00 I2 - FLOOD ZONE A.L.U.C.
LL > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. �I Y❑� N❑ Y [:] N❑
0- 0 (This section need'not he completed if the permit is far one TOTAL
hundred dollar IS 100)or less.)
L) O 1 certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL (- mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California. n�^
d Dam Applicant ALTER OR ADD TO MECH. 5.00 BUILDING lil"Y�
} m NOTICE TO APPLICANT: It,iflur making this Certificate of Ex-
Z anption,you should become subject to the Worked Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE 1
U such provisionsor this permit shall be deemed revoked. AIR HANDLING UNIT TO IOXOCF.M-) 4.00
CONSTRUC('ION LENDING AGENCY AIR HANDLING UNff1OVER 10PWQFMl) 6.00 SEISMIC FEE g - I
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 IS". MICROFILM
3097,Civ.C.). HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lenders No H EATING UN IT(OVER 100,000 B.T.U.) ELECTRIC 5I (OS
Lendcr s Address ,-
1 bcrtify the I have read this upplicmion and slide that the above VENTILATION FAN (SINGLE) 4.00
information is correct, I agree to comply with all city and county PLUMBING
ordinances and slate laws minting to building construction, and BOILER-OO P(3 H.P.or 100,000 B.T.U.) 6.00 I7�
hereby authorize representatives of this city to enter upon the .BOILER-COMP (Over IOQODOBTU)SEE FEESCH. MECHANICAL rLO 13
above-mentioned property for inspection purposes. 'JI
(We) agree t ave, indemnify and keep harmless the City of MISC.- - REFER TO ORD. 519 -
Illicit,I imo agui t Ii66dhtles,Ol .Ic and
colts and expunsus which p CONST.TAX /Pl r �(�
ayin an uccme inri d Cit in cone PERMIT ISSUANCE 10.00 7 D et,
y y y qucoc of the
ranting of permit MECH.CONT. LIC.NO. MECH.
Z /7 TOTAL be) TOTAL / 0,G7
Ore of Applicant/Contractor etc 7 �I
OFFICE COPY