5858 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
m,ILMNGAPPLICATION & PERMIT
ADORES �� ��
® � BUILDING-ELECTRICAL=PLUMBING-MECHANICAL 5858 V
O R'a PLAN CHECK VALIDATION
UTV."" w .' ELECTRIC PERMIT "FEE'
Ianme s , . - ' UTLETS-SWITCHES-RECEP .5.00/1.00
LIGHTING FIXTURES 5.00/1.00 -
CONTRACTOR�s / APPLIANCES-RESIDENTIAL 4.00
PNory 1/ PANELS 5.00
DATE OF APPLICATION
ANIHITECr SIGNS 6.00 PLAN CHECK FEE �. P.C.NO.
on .ENGINEER - LIC,NO s SIGNS TRANS. - 3.00
ADDRESS ENG' SPECIAL CIRCUIT '5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
AMOTORS SEE-FEE SCH. '/tel/i
ADDRESS
oREss -
' SERVICE CHANGE 10.00
w
00 LICENSED CONTRACTORS DECLARATION
a U w hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y (commencing wit ection 7000)of Uivisio 3 s d
¢y BLDG. ELECT. PLC. MECH.
H N Professions Cod• J my license m in full f t ❑ ❑ ❑
O i_ o License C ss_ Lic.Number- ,/�n."(
Date Cont
a y E - B ILOING PERMIT
p Ix a IiRBU1LDli L A"f
o d v INFORMATION
E:
; N I hereby alfnn tlmt 1 am exempt fmm the actor's Llcen a MISC.- REFER TO ORD
u O j Law for the following reason.(Sec.'7071.5,Business and Professions VALUATION .S/FT.
H - g PERMIT ISSUANCE s
w0 Code:Any city or county which'requiresapermit to Con strucl,allet,
¢ s¢ FO improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.N0. - ELEC. r.
imLL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
E
he is(Chapter
d pursuant en the provisions of the Contractor's 3 License '
HiQ Law(Chapler9(commbncing with Section 7000)ofDivision3of the
g 4 D Business and Professions Code)Or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant toa civil penalty, ,ALTER-DRAIN -WATER (EA.) 4.00
of not more than Ove hundred dollars(1500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 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,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4,00 SO,FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
meets are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4 (EA.)• 1.00 BUILDING USE
builder will have the burden of proving that h - .e did not build or im- E IND CON PB - Omer
prove for purpose of sale.). h INDUSTRIAL WASTE INTERr, 20.00 ❑ - ❑ ❑ ❑
❑ I,as owner of the properly,am exclusively contracting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:1'he 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 contractor(,)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sea ,BAP.C.for this
WATER HEATER W/VENT 4.00
reason
Owner Date _ WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WOKKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-a'"e, - ZONING ENG.SITE N0.
/l(\` or a certificate of Workers'Compensation Insurance,or a certified
copy thelVof(Sec.3800,Lab.C.).
Policy No. Company
0 s❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z �iLCertified copy is filed with the city inspection division:
O ,p ant MISC.• REFER TO ORD. Y❑ N❑ Y ❑ No
N CF:RTI FICA'FE OF EXEMPTION FROM WORK Ii RS' PERMIT ISSUANCE 6.00 FLOODZONE. A.L.U.C.
LU > COMPENSATION INSURANCE - , PLG,CONTR. LIC.NO. PLG.
CL O (This section need not be completes) if the permit is for one TOTAL Y-❑ N❑ Y❑ N❑
Z) 2 hundred dollars(SI00)or less.)
U O 1 certify(hat in the performance of the work for which this per, QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL j- mil is issued,I shall not employ any person in any manner So as to
U heconne subject to the Workers'Compensation Laws of California.
0 u Dale 'Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
}
on NOl'ICE TO APPLICANT: If,after making this Certificate of Ex-
emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code,you must forthwith comply•with FEE
U' such'provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 101000C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.F.NU 5.00 SEISMIC FEE
I hereby affirm that t re rs a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the Performance of s ork for which this permit is issued ISec. MICROFILM
3097,Civ.CJ ��7C HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name' �^-A HEATING UNIT(OVER 100,000 B.T.U.M50 ELECTRIC
Lender's Address
I'certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I since to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER•COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTUI SEE FEE SCH. MECHANICAL
ubovo-mentioned properly for inspection purposes.
(We}agree to save, indemnify an ep harmless the City'of MISC.- REFER TO ORD.
s Cup ino ag'" liabilities, ' gme costs and expe ,es which CONST.TAX
I
a w c - st City in consequ ce o he PERMIT ISSUANCE 3,00
gn nl g t p i , b ECH.CONT. LIC.N0. MECH.
Q TOTAL TOTAL
net iMIPApplicriAnCrnuffeb.ir 7 Dire
" r- OFFICE COPY