4630 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN,ONLY "
'' � PERMITNUMBER
BUILDINGPROJECT IDENTIFICATION ` /�PPLICATION $t PERMIT A ��O
\/ am�oimc . ', . ' '
F nooaEss�`D / /L� A��� BUILDING —ELECTFICAL—PLUMBING—MECHANICAL �t
J �� /'�V
� OWNER'S ' .. . _ -._ .. . _ ,___ .
ME PLAN CHECK VALIDATION
�LnT �, I� JI�_ E a��_ // �7Y, ELECTHICPERMIT PEE
c�1' iv rru� b
CONTPpCTORS Q
mnMe . , 3 .OUTLETS-SWITCHES-RECEP 5.00/1.00 � �
� uc.r�o. ' � LIGHTING FIXTUFES 5'.00/1.00 ,._ ^ � �
nooAissroa�s - . . , ppLIANCES-RES�DENTIAL 4.00 , '
. aHONE PANELS � S.00 DATEOFAPGLICATION
,ARCHITECT � � � PLANCHECKFEE P.QNO.
' or+ , SIGNS • ' 6.00 . � � .
ENGINEEP ' � �
" uc.No. ' SIGNSTRANS. � 3.00 '
• nooa�ess E�c. . , � ' SPECIAL CIRCUIT. 5.00 PEFMIT VALIOATION . I
' � zia � EMP.METER OR POLE INS. 15.00 ^ - "
. APPLICANi'S •
� nooRess � - � MOTORS SEE FEE SCH. S � . '
� - , . . � SERVICE CHANGE 70.00 ///�/LS I
w o o � LICENSEUCONTRACTORS UECLARATION , ��
• Q �G � I hereby affirm that I am limnud under provisions ofChap�er 9 ' ISSUANCE oATE
N �"' (commencing with Section 7000)of Division 3 of Ihe Business and i
� BLDG. ELECT. PLG. MECH.
r y i Pmfessione Code,and my license Is In full fome entl effem. � ❑
i o m — Licenu Clnss' Lia Number ,�/ la` �,� � � �
� y r w Dnfe Con�racmr � �{,� ,��t ��-�� �����
��f� � Y P ` BUILDING PERMIT
a Y a a ' OWNf:R-BUILDER DLCLAftAT10N � I
¢ o a � • INFORMATION
w ; � I hereby affi�m thut I um exempt trom HieCon�mcmr i License MISC.— � REFER TO ORD
LL o c Law for tl�e followin reasoa(Suc.7031.5,Businessand Pmfessions �./ VnLUATION $/FT.
r — � . e PERMIT ISSUANCE � 6.00 n ^
Code:Any city or counry which requires o pmmil fo ronshuct,elter,
� Q ¢p improve,demolish,or repait any s[mc[ure,ptio�to i�s issuance,olso ELEC.CONTR; LIG N0. ELEC. '
a 0� requires lhe applicant for such permit�o lile a signed s�ulement tlwt T�TAL /(���� pERMIT TO �
I 6 w $ ha is licensed pursuant to the provisions of lhe Com�xemi e Llcense
rii Luw(Chap�er9(commencingwith5ec�ion7000)ofDivision3ofthe tz�L pC'. f�L,Bt� �
' a Business and Pmfessions Code)or tl�at he is exempt�herefrom and V. PLUM8ING PERMIT FEE , T
� ¢ r $ �he basis for[he alle ed cxem tion.An I
g p yviolationoPSec�iun7031.5 STOFIES TYPECONSTR.
a3 � byanyapplicamforapermitsuAjects�heapplicanR�iucivilpenalty, qLTER-DRAIN&VENT-WATERIEA.) q.00
�� of no�more thun five hundmd dollars(8500)J: ' '
' ❑ 1,as owner of[he property,or my employres with wages as :gqCK F LOW PROTECT. DEV ICE Z,OO OCC.GROIIP qEs:urvrt5
, �heir sole compensalion;will do�he work,.�nd the s�mc[ure is m[ ,
' 'intended ar offercd for sale (Sec. 7044, Busincss unJ Professions, DRAINS-FLOOR;ROOF,AREA,COND. 4,00 . '
, CoJe'.The Contracmr's License Law does not epply m an owner of ' ' .
� pfOp¢![y�WhUbpl�(�SOf1O1proVC5�h2lCOO�OO�WhOdOf554LhW0lk � FIXTURES-PERTfiAP � 4.00 S�.FT.FLOOFABEA TOTALpCREAGE
- . himselC or Ihrou6h hie awn emPloYccs.Provided tha[such imtirove-, . � •
mentsaremtincendeduro(feredforsale.lf,howeveqthebuildiny GAS-EA.SVSTEM-11NC.40UTLET$ 4.00 i
or impmvement is sold within one year of completion,H�e ownerv GAS-EA.SVSTEM-OVER 4 (EA.�' 7,00 BUILDING USE
builder will have thc burden of proving�hat he did nof build or im- qEs iNo CON Pe Omer, I
proveforpurposeofsaleJ.' • INDUSTRIALWASTEINTER. 20,00 � ;� � � � �
❑ I,as owner ol"the property,am exclusively tontrecting with ,
licensed contmc�ors m constmct the pwjec�(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 � ' nssEssorasvapce��uo.
.and Professions Code:The Contracmr's License Lnw Joes nof upply ' ,
�o an owner of propeny who builJs�ir imFlmves thereon,ond who IAWN SPRINKLERS-OVER 5 (EA.) 7.00 . , ' '
emitmc�s for such pmjec�s wilh a mntroctoHsl licensed pursuant m '
' �heContmcmr'sLicenseLuw. • SEWER-SANITARV-STORM EA.200fd8.00 lqqcrNo. rnRce�NO.
. ❑ lu x� pui��Sc ,e.&P.C.furthis yyqTERHEATERW/VENT. � 4.00 � •
rcason
' } �Date WqTER SVSTEM 4.00 � ` ACC.DATE ACF FLLE NO.
WORKERS'COMP6NSATIONUBCI.AR TION . W/{TERTREATINGE 4.00 ' .
I hereby allirm[ha� I have a cer[ifica[e of coreen[fo selhinsure, . ' . '
or a rer�ifica[e of Workers'Compenwtion Insurance,or a cer[ifieJ ' ' ZONING ' ENG.SITE NO.
copy IhereolfSec.3800,Lnb.C.7. � � ' , . ; ' � � -
. Policy No. - Compuny - - � �
Q ' ❑ Cef[iliedcoOY�she�ebyfumished. + F�RESPFINK ENEFGVT-24
Z Z , ❑ Certified copy is filed wl�h the ci�y inspec�ion �ivision. �
� . APPlicant ' . MISC.' , WD. v � N� v � N� �I
�.N � �C6RTIFICATF:OFEXEMPTIONf'ROMWORKER$' PERMITISSUANCE. . - 6.00 W� c�ooDZONE A,�.U.C.
' W � COMPENSATION INSURANCF., PLc.CONTR.' . LIC.No. ' p��, � � ,. Y O N❑ . ❑ NO
a O (This seclion need not be completed if[he penni� is for one - TOTAL '
. � 2 hundreddoilars(SI00)orlusJ '
� �U O '�certiry that in �he performance of�he work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARV "
LL F mi� is issued,1 shall not employ any person in any manner so us[o , '
O W berome subjecl�o lhe Workers'Compensmion Laws of California. '
y Uate � - Applicant ' 'BUILDING
} m NOTICE TO APPWCANT: If,ulter niakin�ihis Certificute of Ex- ALTER OR ADD TO MECH: 4.00
F ? emption,you should become subject�o�he Workers'Compensu�ion qppLIANCE ' '4.00 PLAN CHECK
provisions of'�tlie Labor CoJc, you mus[ fartliwi[h camply with .�FEE �
U such proyisions or this permit shall be deemed revokeJ. � , AIR HANDLING UNIT(TO 10,000QF.M.) 3.00
�. CONS7RUC710NLeNUINGAGENCY AIRNANDLINGUNITIOVER10,00DGEM.15.00 SEISMICFEE
' 'I hereby affirm �hut Ihere is a constmction Iending agency for . EXHAUST HOOD(WITH DUCT) 2.00 ' �
. the performance of the work for which�his permi� is issued 1$ec. MICROFILM
, 3097,Civ.C.). - ' . � HEATING UNIT(T0100,000 B.T.U.) 4.00 -
' . LenJer'sName HEAT�NGUNIT�IOVER100,OOOB.T.U.�7:50 �� � -
� LenJeriAddress '- ELECTRIC
Icenify �hatlhavereadthisnpplicationundstate�hattheubove VENTILATIONFAN �SINGLE� � �� 3.00
� �informa�ion is rorrect I agree fo mmply with all city and cuunty PLUMBING Q �
oNinunces and stme laws relating to buiidiny constmc�ion, anJ BOILER-COMPI3H.P.or100,0008.T.U.) 4.00
hereby authorize representatives of �his city to entcr upon the g01LER-COMP (Over100,000BTU1SEEFEESCH. MECHANICAL
above-menlianed property forinspec�ion purposes. '
(We) agree to save, indemnify and keep harmless the City oi MISC.- ' REFER TO ORD.
Cuper[ino against liabili�ies,jud6ments, ros�s and expenses which pERMIT ISSUANCE 3.00 ' CONST.TAX '
ma �n any wey owrue egainst suid City in conseyuence of he '
g n��'Ig0(lhispe�pti[. , MECH.CONT. LIC.NO. . MECH. � '
', . � . ' v.�, /s2/ T��"` TOTAL
igna[u�eofApplicam�Cm �acm� Dat / �
• ,� � . � � - . OFFIC�GQPY - . .. . . �
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