12129 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT 1 DENTI FICATI ON PERMIT NUMBER
BOILOING APPLICATION & PERMIT
ADDRESS _ 12129
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
GwNER'S - PLAN CHECK VALIDATION
N,A QTV. ELECTRIC PERMIT FEE
_ PRDNEass- s
CONTRACTORS O
NAME pp 5 UTLETS-SWITCHES-REC€P 10.00/1.00 (f,
S eTs2N� LIC No 13 d LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
A DRESS
O W.�
PHONEL, PANELS 10.00 DATE OF APPLICATION
ARCHITECT
OR200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC,No. SIGNS TRANS. 3.00
AARCH OR DDRESS ENG. SPECIAL CIRCUIT 5,00 (J µ PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 -
Avvucnrvrs MOTORS SEE FEE SCH. x
ADDRESS
SERVICE CHANGE - 20:00y/
o o LICENSED CONTRACTORS DECLARATION I I ' I
u u 1 herebyaffirm that 1 am licensed under provisions of Chu ter 9 'i r
Na n (commencing with Section 7000)of Division 3 f the Busin ss and '1 '7 ISSUAN E DATE
% +• BLDG. ELECT. PLG. MECH.
H D i Professions Codr,,ind my license is in full far Sort f
i O��% License CIaPs_ 1S_._. Number I�
o F Z Lice1C /u T�I_fo_p=Contractor �' t`,
BUILDING PERMIT
a wOWNER-BUILDER DECLARATION
K ; LL 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD INFORMATION
F LL 0 j Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 /� VALUATION S/FT.
Code:Any city or county which requires a permit to construct,alter,
oimprove,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC.
u requires the applicant for such permit to file a signed statement that TOTAL
n w m he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
HiQLaw(Chapter 9(Commencing with Section 7000)of Division 3 ofthe 6�� )Z44-r
4 D Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE 7 /
X H the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a3 � by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of Not more than five hundred dollars(5500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
(S
their sole compensation,will the work,and the structure is not
intended or offered for sale(Sea 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 �y
Code.The Contractor's License thereon,
does not apply to an Owner of J
himspropelf
who builds his improves
emplo employees,
and whoat oes such Improve-
work .3 FIXTURES-PER TRAP 5.00 sa PT.FLOOR AREA-TOTAL ACREAGE
himself re through his own employees,sale.
Iprovided,ho that such improve-
ments orimprovemeintcndedor withieroneyaro I Lhoweveg 0th building GAS-EA.SVSTEM-11NC.40UTLETS 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 im- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
prove 1,aso neerose of sale.). RES INDUSTRIAL WASTE INTER. 30.00 1:1
I❑ ❑N ❑ Other❑
❑ d as owner of the property,he exclusively contracting with
licensed contractors to construct the project(Sec. does Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The hContractor's License s thereon,
does not apply
to tr owner of property who builds or improves need pursuant
and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contradortsl licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
O I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT - 6.00
reason
Owner Uate WATER SYSTEM _ 5.00 ACC.OATE ACC.FILE NO,
WORK E RS'COMPENSA'fION DFCLARAI'ION WATER TREATING EQUIP,^ 5.00
1 hereby affirm that I have a Certificate of consent to self-insure,
or a certificate of Workers'Com pen. on Insurance,or cetlified _ ZONING ENG.SITE NO.
copy thercof(Set,3800,Lab.C.). T, 2'
Policy No. Company lK.
C) ❑ Certified copy is hereby furnished r FIRE SPRINK ENERGY T�29
F OZ X CeNific Copy tiled MISC.- REFER TO ORD, v
,. y_Mspcct ion Aivision. ❑ N O v ❑ N❑
_ APPlicmr- -Sym
� N CERI'IFICAI'fi 017 EXEMPT ION FROM WORKERS' PERMIT ISSUANCE 10.00 Q ""cFLOOD ZONE A.L.U.C.
UJ > 4704I7NSAT10N INSURANCE, PLG.CONTR. LIC.NO. PLG.
Q• � �aL
Q (This section need not be completed if the permit is for one TOTAL oC3 Y Y ❑ NE]
Z hundred dollars(S 100)or less.)
U� O 1 certify that in the performance of the work Her which this per. TY. MECHANICAL PERMIT FEE FEE SUMMARY
LL f- mit is issued,I shall not employ any person in any manner so as to
O become subject to the Workers'Compensation Laws of California.
n Date Applicunl ALTER OR ADD TO MECH. 500 BUILDING
>_ N NOTICE 70 APPLICANT: If,after making Ihis Certificate of Ex .
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK I
provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall be deenmd revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10000 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 performance of the work for which this permit is issued(Sec. MICROFILM
3097,CN.C.). HEATING UNIT(TO 100,000 B.T:U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000&T.U.19.50 ELECTRIC `3d 02
I certify that I have read(his application and state that the above VENTILATION FAN (SINGLE) 4.00md�
information is correct.I agree to comply with all city and county
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
hereby above-mentioned
representatives forms of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEESCH. MECHANICAL f/(J
hereby
authorize
properly for inspection purposes.
lWe) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
A
pliabilities,judgments, costs and expenses which �, CONST.TAX
ay in any w accrue against-said City in consequence of the PERMIT ISSUANCE 10.00ran ting off
l is lernit. MECH.CONT. LIC.NO. MECH.
I TOTAL TOTAL
ignature of App ican .ontrector Dat{
OFFICE COPY