4623 '�/ICANT TO FILL IN,INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICAT - PERMIT NumeER
So LDING APPLICATION & PER _ _ _ _ 4623
t aD OAzr�REBS 'e•e•Gx•/ '
BUILDING — ELECTRICAL—PLUMBING —MECHANICAL
oem'" - - - - - PLAN CHECK VALIDATION
/Y NAME Jam/ QTY. ELECTRIC PERMIT FEE
("L PHONE
CONTRACTORS r -
NAMr U OUTLETS-SWITCHES-RECEP 5.00/1.00
LIC.No LIGHTING FIXTURES 5.00/1.00
CONTRA
REI �V/ 'lp APPLIANCES-RESIDENTIAL 4.00
Ano
REss 4*�Cr
1 PANELS 5.00 DATE OF APPLICATION
ARCHITECjJ-�//fJ SIGNS 6.00 PLAN CHECK FEE .P.C,NO,
OR
ENGINEER p - Llc:NO, SIGNS TRANS. ' 3.00
ARCH.OR ENG, SPECIAL CIRCUIT S.00 ,PERMIT VALIDATION
ADDRESS -
• t
•I ZIP EMP. METER OR POLE INS.
aPPucarvrs
AOORC55 .. - MOTORS ''. SEE FEE SCH. S
t - '
SERVICE CHANGE 10.00 ���.
w o
LICENSED CONTRACTORS UECLA RATION •.
Q o u• I hereby affirm that I am licensed under provisions of Chapter 9 - ISSUANCE DATE
.y a n (commencing with Section 7000)of Division 3 of the Business and 4 CT P G. MECH.
r,N z Professions Cod n my license is m full burp', �,I 8 s�' ❑
z O,A License Class Lic.Number u
L —G Date Contractor 0 '
v�0*5 Y
rc m X a WNGR-BUILDER UECLA RA'T'ION I (RUT [glfllQy$.ER N
' 0a" - MISC.— REFER TO ORD 1 ION
w ; H I hereby affirm that I am exempt from the Contractor's License
LL O j Law for the following reason.(Sec.7031.5.Business and professions .PERMIT ISSUANCE 6.00 ? V�-uanON- S/FT.
wig Code:Any dryer county which requires a permit to'construct,alter: ELEC.CONTR. LIC.NO. 3,
re it O , improve,demolish,or repair any structure,prior to its issuance,also ELEC..
O 2 requires the applicant for such permit to file a signed statement that , TOTAL PERMIT TO WI
,U`4
m" he is licensed pursuant to the provisions of the Contractor's License ' '
Fzi Law(Chapter 9(commencing with Section 7000)of Division'30f the.
a Business and Prof'es'sions Code)brthat he is exempt therefrom and CITY. PLUMBING PERMIT FEE
r m the hasis fur the alleged exemption.Any viohiticn of Scelion 7031.5 - - STORIES TYPE CONSTR.
.by any appliewit lora penult subjects the applicant pia civil l,enauy ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(S500)J:
❑ .l,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 Its re through his own employees.for W If,ho that such improve- -
mmselfo through his
oroferprided that such
the mprovbuilding GAS-EA.SYSTEM-11NC.40UTLETS 4.00 _
or improvement is sold within one year of completion,the Owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or un.prove-Ior Purpose ofsale.). INDUSTRIAL WASTE INTER. RES IND CON PB Other
❑ I,as owner of the property,am exclusively contracting with 20.00 ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and ProfessionsCode:The Contractor's License Law does not apply
to an owner of,property who builds or improves thereon,and who LAWN SPR IN KLERS-OVER 5IEA.) 1,00
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200h/5.00
the Contractor's License Law. TRACT NO. PARCEL NO. .
❑ 1 alit exempt under See,—,HAP.C.Ru this WATER HEATER W/VENT 4.00
reason
• Dam - Owner - WATER SYSTEM 4.00
ACO.DATE ACC.FILE NO.
WORKE,RS'COMPENSATION DECLARATION WATER TREATING'EQUIP. 4.00
1 henchy affirm that I hove a certificate of consem Ie self-insure,
ora nrtifi, f Workers Compensation Insumnc'e,or II certified - -ZONING ENG.SITE NO.
cop IhLre f(Sc 3800 LahC.)'
I y NO, nnpunY
Cetli bd y Ix hereby turn' bed.
Z Z ❑ art if it s' dcd I divicine. FIRE SPRINK ENERGY TY9
O1 MISC.- REFER TO ORD.
O PPbunit V ❑ 'N❑ Y ❑ 'N❑
K y Ii RTI/ ICATE OF IiXF.MI'TION PROM WORKIiRS• PERMIT ISSUANCE 6.00 FLOODZONE, A.L.U,C.
LU ! COMPENSATION INSURANCE' - PLG:CONTR. uC.No. PLG,
CL Q IT Is acctf ton•nee I mol be completed if the Permit is for One 'NOTAL -v❑ N❑ Y ❑ No
bund cd d/111ars 151001 or IessJ
(> O I c ff$$''that in the performance of the work for which this Per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner xn i Io
U become subject to One Workers Conloensation Laws Of Callfomia.
i Dale Applicant ALTER OR ADD TO MECH. 4,00 BUILDING'
} to NOTICI7 TO APPLICANT: If,after making this Certificate of fix.
� ? emotion,you should become subject to the Workers Compensat ion APPLIANCE 4.00 PLAN.CHECK
provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit sha11'he deemed revoked. AIR HANDLING UNIT ITO 10=C.F.M.) 3.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F,M.).5.00 'SEISMIC FEE
- I herahy affirm that Iheie is a canstructim, lending agency for EXHAUST HOOD (WITH DUCT) 2.00 _
Om pLrb rnaulce of the work for which this permit is issued(Se -
3097,Civ.C:l. - a HEATING UNIT(TO'100,000 B.T:U.) 4.00 MICROFILM
Lender's Name HEATING'UNIT(OVER'100,DOOB.T.U.)7.50 ELECTRIC,
Lender's Address
I certify that I have read thisapplication and slate that the above VENTILATION FAN (SINGLE) 3.00 infonnation is correct. 1 agree to comply with all city and county BOILER COMP PLUMBING -
ordinances and state laws relating to building construclien, and (3 H.P.or 100,000 B.T.U.) 4.00
hereby authorise representatives of this city'Io enter upon the BOILER COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
abuvo-menlioned property for inspection purposes.
(We) ag"" to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
C ertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
'n any way accrue ins( mid City in conseyucnc0 of the
g Ming•of'ltisoermit _ MECH.CONT.' LIC.NO. MECH.
TOTAL TOTAL 7 9
k4goaturc of Applicant/Contractor Dale •,..e.
OFFICE COPY