10285 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATION PERMITNUMBER
BUILDING APPLICATION & PERMIT 10285
1
7 ADDREss
fp s� eeit100 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
O NER'a PLAN CHECK VALIDATION
(/)') �® oNE�5 ��Up� T7Y, ELECTRIC PERMIT FEE
NOMERACTORs Itr Corr C UTLETS-SWITCHES-RECEP 10.00/1.00 /r?('
LIC.No, LIGHTING FIXTURES 10.00/1.00
ADDREss TORS APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT
On PANELS (OVER 200 AMP) 20.00 PLAN CHECK`7
P.C.NO.
ENGINEER
LIC.No, SIGNS TRANS. 3.00
ARCH.OR ADORESS ENG, SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP frEMP.METER OR POLE INS. 20.00
T S
ADDRESS MOTORS Ain SEE FEE SCH.
SERVICE CHANGE 20.00
BE O LICENSED CONTRACTORS DECLARATION TEMP.POLE 10OP, 30.00
a 0 u 1 hereby affirm that I am licensed under provisions of Chapter 9
F i w ISSUANCE DATE
(commencing with Section]00e)i of Division 3 0!the ef Business and ELECT. PLG. MECH.
as i Professions Code,and my license is in full force and effect. 1nO ❑' EJ 2 O - License Class Lic.Number06 710
NE W Date Contractor
Be e Be¢ OWNER-BUILDER DECLARATION BUILDI G PERMIT
X ;u m I hereby affirm that I am exempt from the Contractor's License IMISC.- REFE O ORD INFORMATION
H u O at Law for the following reason.(Sec.7031.5,Rosiness and Professions VALUATION
Code:Any city or County which requires u permit to construct,alter, PERMIT ISSUANCE 10.00
f w ELEC.CONTR. LIQ NO.
e ¢ ¢O O improve,demolish,or repair any structure,prim to its issuance,also ELEC. �Q -
e requires the applicant for such permit to file a signed statement that TOTAL
r PERMITTO
a. E
8 he is licensed pursuant to the provisions of the )ofDicmr's License C L G7
H z¢ Busi(Chang Professions
de)with Section is exempt
of the
BE e O Business and Professions Code)or Oral he is exempt actio rota and QTY. - PLUMBING PERMIT FEE
BE H $ the basis for the alleged exemption.Any violation t Ion
en LS STORIES " TYPE CONSTR.
n ; � by any more tha fora permit subjects S500).he licum tm civil penalty ALTER-DRAIN VENT-WATER (EA.) 5.00
of not more owner
floc hundred dollars my em:
p. L as owner at the property,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 structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property Who builds or improves(hereon,and who does such work F IXTUR ES-PER TRAP 5.00 SQ FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees provided that such improve-
or nts improvement
not intended w thinoffered
onefor
year
Ir,however,thebuildingowner.
GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner
builder will have the burden of proving that he did not build or int- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of sale.). RES IND CON PB Otha,
❑ 1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ o ❑ o
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 of improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contraclnr's License Law. SEWER-SANITARY-STORM EA.200(t/10.00 TRACT NO, PARCEL NO.
❑ 1 am exempt under Sec.-,R,&P.C.IN,this
ason WATER HEATER W/VENT 6.00
Orewner Date - WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENS TION DECLARATION WATER TREATING EQUIP, 5.00
I hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy t1u,n of(Sec.3800,Lab.C.).
Policy No. Company
0 ❑ Certified copy is hereby furnished. RE SPRINK ENERGY T-Z4
Z Z O Certified Copy is filed with the city inspection division. FIRE
v N4
O Applicant MISC.- REFER TO ORD.
it Lo CERTIFICATE OF EX17MI'TION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONEA.Lu.L.
LU > COMPENSATION INSURANCE PLG.CONTR, LIC.NO. - PLG. � N� v � N�
Z
d O (This section need not be completed if the AL Yp permit is for one TOT
hundred dollars(5100)ar less.)
U O I certify.that in the performance of the work for which this per- OTV MECHANICAL PERMIT FEE FEE SUMMARY
LL )- mit is issued,I shall not employ any person in any manner so as to
0 W become subject to the Workers'Compensation Laws of California.
a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} w NOTICE.TO APPLICANT. If,after making this Certificate of Fx-
2 em tion,you should become subject to the Workers'Compensation I- - p.. y p APPLIANCE 5.00 PLAN CHECK
soonu?nn i the Labor Code, you must forthwith comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000 C.F.M.) 4.00
CONSTRUCTION LENDING AG17NCY AIR HANDLING UNIT(OVER 10=C.FM.) 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 Name"
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)9.60 ELECTRIC L.
1 certify that I have read this application and state that the above , VENTILATION-FAN (SINGLE) 4.00
Vinformation is correct. I agree to comply with all city and county BOILER H.P.Or 100,0008.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives talions of this city to enter upon the BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly for tativsp of
purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cup?1 to against liabilities,judgments, costs and expenses which CONST.TAX
may i any w y ace a agai st said in consequence of the PERMIT ISSUANCE 10.00
gratin ft permit MECH.CONT. LIC.NO. MECH.
TOTAL
Sign e m
plmam/Con e or / Date TOTAL
OFFICE COPY