11006APPLICANT TO FILL IN INFORMATION. WITHIN RED LINES — USE BALL POINT PEN ONLY
BU LD1 NG PROJECT I DENTI FICATI ON
APPLICATION & PERMIT
BUILDING —ELECTRICAL— PLUMBING —MECHANICAL
PERMIT NUMaER
BUILDING
ADDRESS
F t
OWNER'S -
"AME IsaA_
QTY. ELECTRIC PERMIT FEE 1
PLAN CHECK VALIDATION
'
J 1 PHONE
..
CONTRACTORS - -
NAME .
OUTLETS -SWITCHES -RECEP. 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
DTRA ns
CON
ADRESS
01 Ilwl —4 PHONE
DATE OF APPLICATION
PPLIANCES- RESIDENTIAL 4.00
PANELS 10,00
ARCHITECT T1elM0l1`f'
OR
ENGINEER
LIC. NO.
PANELS(OVER 200 AMP) 20,00
PLANCHECKFEE P.C. NO.
,
SIGNS TRANS.' 3.00
ARCH. OR ENG.
SS
SPECIALCIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS.. 20.00
ZIP
APPLICANT'S u `(�`�� IL�J Erf
ADDRESS ' 1 �1VU
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
{{
I�7`/�CENSED
• 14*
LICONTRACTORSDECLARATION
-"
I hereby affirm that 1 am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions C�q4c,p�Id,,nnsy license is in full for yq�tJ!yyf C
Lic. Numbe §t
License Class LIC
ISSUANCE DATE
a
-'
BLDG.
❑
ELECT.
❑
PLG.. MECH.
❑ ❑
Date—C.ntractor.�tl—('1}�\�C�+
-
BUILDING PERMIT
INFORMATION
- OWNIi R -BUILDER DECLARATION I n�
I hereby affirm that 1 am exempt from the Contractor's License
Law forthe following reason. (Sec. 7031.5, Business and Professions
Code: Any city or county which requires a permit to construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also
lie vires the dp arsatrat to Such permit to file a Signed Statement that
La islicensed9(ecroltto the
ngprovisions Of 700'f.'lof Division
of t theref o and
Law (Chapter 9 (co moos Code) .,Section is exempt
Business and Code) or that he is exempt therefrom and
MISC. — REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
-$/FT.
ELEC. CONTE. LIC. NO. ELEC.
• • TOTAL
-
QTY. PLUMBING PERMIT FEE
- PERMIT TO
�1� �
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
he alleged
malty
by any applicant fora permit subjectsthe $500).licant toacivil penalty
of not more than five hundred dollars (5500).1:
ALTER-DRAIN&VENT-WATER(EA.) 5.00
❑ 1, as owner of the properly, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE - 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended or offered for sale (Sec: 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
property who builds or Improves thereon, and who does such work
himself or through his own employees, provided that such improve-
ments are not intended oroffered for sale. if, however, the building
F IXTUR ES - PER TRAP 5.00
50. FT. FLOOR AREA
TOTAL ACREAGE
,
GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year o1' completion, no, owner-
builder will have the burden of proving that he did not build or im.
prove for no pose.mf Sale.).-
❑ 1, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
RES IND' CON PS .Omer
❑ ❑ ❑ ❑ ❑
. .
INDUSTRIAL WASTE INTER3000
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License. Law does not apply
town owner of property who builds or improves thereon, and who
LAWN SPRINKLERS- 1,INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 1.00
ASSESSORS PARCEL NO.
,
contracts for such projects with a contractorts) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00,
TRACT NO.
PARCEL NO.
❑ Iamexempt underSec.' ,HAP.C.for this
reason -
WATER HEATERW/VEN Cl tdb
Owner - Date
WATER SYSTEM 5.00
ACC. GATE-
ACC. FILE NO.
WORKI?RS'COMPf:NSATION DECLARATION
WATER TREATING EQUI PCM 01 1,131,1916d
I hereby affirm that I have a certificate ofemment Ioself-insma.
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG: SITE NO.
Copy thergp�(,;Gj�§ OO, Lab.C.)T p _.tr—
Policy No Company S 61
❑ Certifie py is yfurnished
Cel e — _ 'th the division.
Apll ant
FIRE SPRINK
v-❑ N❑
ENERGY TZ4
Y❑• N❑
MISC.- 1'� REFER TO ORD.
CERTIFICATE 01: I:X EMPT10N FROM WORKERS'
PERMIT ISSUANCE, 10.00 -
FLODD ZONE
A. L. U.C.
PLG. CO NTH. LIC. NO. pp
n 80
PLG.'
TOTAL
' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one,
V ❑' N❑
V ❑ N❑
hundred dollars IS 100) or less) '
I certify that in the performance of the work for which this per.
mit is issued. I shall not employ any person in any manner So as to
become subject to the Workers' Compensation Laws of California.
Date ApplicantALTER
OTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, after making this Certificate of [Ex-
emption, you should become subject to the Workers' Compensation
APPLIANCE - 5.00
PLAN CHECK
provisions of the Labor Code,'you'must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (TO.10,000C.F.M.) 4.00
FEE
AIR HANDLING UNIT (OVER 10 C.F.M.) 6.00
SEISMIC FEE
CONS'T'RUCTION LENDING AGENCY
1 hereby affirm that there is a construction loading agency for
EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.)
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
H EATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
Lender's Name
Lender's Address
1 certify that I have read this application an"state That the above
VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all eity and county
ordinances and,smte laws relating to building construction, and
- -
BOILER-COMPI3H,P,Or 100,000B.T.U)�6.00
PLUMBING16
:BOI LER-COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned properly for inspection purposes.
MISC. - REFER TO ORD.
to save, indemnify and keep harmless the City of
st liab' i'es, judgments, costs and expenses which
ay . u against said City i consequence of the
p It
XialtuAppliMni/tolont.,
CONST. TAX
PERMIT ISSUANCE 1000
MECH. CONT. LIC. NO.
MECH.
cDate
TOTAL
TOTAL
t ~