8462 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
"'BUILDING PROJECT IDENTIFICATION I
PERMIT MBER
GILDING APPLICATION & PERMIT
AooREu C Pie 211.10, cA 43512 4 6 2
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'$NAME DTV. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
Poi�/�� /'� q6p /9
.AME
OAMRac7ogs UTLETS-SWITCHES-RECEP 10.00/1.00
11C.NO, LIGHTING FIXTURES 10.00/1.00
ADDRESS TOAs PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE GA.NO.
OR - PANELS (OVER 200 AMP) 20.00
ENGINEER
uc.NO. SIGNS TRANS. 3.00
ADDRESS ENR. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
0 0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a i w I hereby aflinn that I am licensed under provisions of Chapter 9 ISSUANCE GATE
a n (commencing with Section 7000)of Division 3 of the Business and
r D i Professions Code,and my license is in full force and effect. B D ELECT. PLG. MECH.
z o u, - License Class Lic.Number ❑ ❑
O � -O
so Data Contractor
Q y E J
W ¢w a OWNER-BUILDER DECLARATION BUILDING PERMIT
S o a INFORMATION
w;u. I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u O j Law for the following reason.(Sec,7031.$,Busincssand Professions VALUATION
- I, PERMIT ISSUANCE 10.00 S � S/FT.
m y Cade:Any city Or county which requiresa permit to construct,ah'q
IL K Q O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO.
ELEC. /
0 LL requires the applicant for such permit t0 file a Signed statement that TOTAL PER
T TO
w es m he is licensed pursuant to the provisions of Ilia Contractor'.%License
r z a Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe FEE o
q i et Business and Professions Code)or that he is exempt therefmm and DTV. PLUMBING PERMIT
r es the basis for the alleged exemption.Any violation of Section 70315 TORIES TYPE CONSTR.
e_ by any applicant for a permit subjects the applicant o a civil penalty ALTER-DRAIN 5.00 c'
of not more than five hundred dollars($500).): -
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECTDEVICE 4.00
their sole compensation,will do the work,and the structure is not . OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAWS-FLOOR,ROOF,AREA,CON D. 5.00
Code:The Contractor's License Law does not apply to an owner of
Property who builds or improoT
vas thereon,and who docs such work FIXTURES
Plants
TRAP 5.00 So.FT.FLOOR AREA rALACREAGE
himself or through his own employees.provided that such improve-
mentsarenotintendedoro(fered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvmnent is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove 1,as ownerose
of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IN D PB Other
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ El ❑
licensed contractors lin construct the project(Sec. 7044,Business - LAWN SPRINKLERS-1 INC 5 V.B. 6.00 gSSESSo P
and Professions Coof The Contracto s License Law does not apply CEL NO.
to an owner of property who builds r improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contra'As for so eta with a co
raetor(s)licensed pursompt to
the Con rs License w. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
�( reason)am empt undo e . ,BAPTC.tor this WATER HEATER W/VENT 6.00
Owner -
Data WATER SYSTEM 5,00
(( R(�"DO RCC.DATE ACC.FILE N0.
WORKER$'CBI II'ENSATION GCLARATION WATER TREATING EQUIP: 5.00
I hereby affirm that I have it certificate of consent to set Ginsure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sce.3800,Lab.C.).
Policy No. Company
0 0 Cetiflnd copy is hereby furnished.
Z Z O Certified copy is fled with the city inspection division. FIRE SPRINK ENERGY T"24
F o Applicant MISC.- REFER TO ORD. Y ❑ No Y 0 N[:)
W CIiRT'I FICATE OF IiXEh1I'1'ION PROM WORKERSPERMIT ISSUANCE 10.00
W > COMPENSAT']ON INSURANCE PLG.CONTR. FLOOD ZONE A.L.U.C.
CL LIC.NO. PLG.
(This section need not be compacted if the permit is for one TOTAL v 0 NY 0 N�
0 C) hundred ly limsthat in the
or less)
LL I- I Certify that h the to employ
of the work for which this per. MECHANICAL PERMIT FEE SUMMARY
H mit is issued. I shall not em to GTY-
0 O p y any person in any manner is to FEE
O w become subject[o the Workers'Compensal ion Laws of California.
CL
Date Applicant ALTER OR ADD TO MECH. BUILDING S'O J�
} m NOTICE TO APPLICANT: If,alter making this Certificate of Ex 5.00
F Z emplion,you should become subject to the Workers*Compensation APPLIANCE 5.00 PLAN CHECK ��
Provisions of the Labor Code, You must forthwith comply with FEE �"�
U such provisions or this Permit shall be Aeemed revoked. AIR HANDLING UNIT(TO 1Q000C-F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE a�
1 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.0 L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATINGUNIT(OVERIOO,000B.T.U.)9.50 ELECTRIC
"certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct I agree to comply with all city and county PLUMBING
ordinances and stat, laws ting to building construction, and BOILER-COMPOH.P.o-100,000B.T.U.) 6.00
hereby authorize represent' i s of this city to enter upon the BOILER-COMP
above-mentioned property to i pectin,purposes. (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
o save, inde no y and keep harmless the City of I F TO ORD.
par ugains iabilities,j d meats, costs' and exile es which � CONST.TAX
ay m any wa rue ag s said City in consegpe lc o the PERMIT ISSUANCE 10.00
gaming Of ilii per if. MECH.CONT. LI Q H.
Signature of plicant/Contract r Dat p( T TAL TOTAL 014
Com L%at OFFICE COPY