13258 S}1ar�it IBaFT3� Z•sc . Com. e,
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
BUILDING PROJECI IDENTI FIC ION - PERMIT NUMBER
UILDIN I
ACnRESG I - APPLICATION & PERMIT _ q n r
L—I�,b4 JlsrA �IC• BUILDING —ELECTRICAL—PLUMBING—MECHANICAL G `J
nWNER'S' . PLAN CHECK VALIDATION
NAME
C r►� 1, O - OTY. ELECTRIC PERMIT FEE
G,, ,2
PHONEE
CONTHACTO&'S -
rvAME -"{��i*• q JOUTLETS-SWITCHES-RECEP 10.00/1.00
-J—14-0 On.NO.Z /p�j Y7 16 ILIGHTING FIXTURES ' 10.00/1.00
ADDRESS R's'WLI C/ `Ir, s�• APPLIANCES-RESIDENTIAL 4,00
CONTRA V L6.w �i
CM' PHONE-VIS-�, PANELS 10.00 DATE OF APPLICATION
ARCHITECT Srtv�e� AJ do)-* PANELS (OVER 200 AMP I 20.00 PLAN CHECK FEE P.C.NO.
OR (/!i �M�
ENGI
LIC.rvo, SIGNS TRANS, 3.00
nooses eNQ, SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
0 0 LICENSED CONTRACTORSIDECLARATION — i— "✓/ C
Sc u U 1 hereby affirm that I am licensed under provisions of Chapter 9 /j(T ( r,e4ti ISSUANCE DATE
vHi 4% (commencing will,Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F D z Professions C `,an license is in full lb A -0 Iii at, ❑
Z,i= D Licens
Class = Lic.Numbe _ 7 - ❑ ❑
m r J Dete Contract
y s a OWNER-BUILDER DEC BUILDING PERMIT
_ a w INFORMATION
wodoMISC.— REFER TO ORD
; n w I hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
Fu0J Law for the following mason,(See.7031.5,Business and Professions - PERMIT ISSUANCE 10.00
Code:Any city or county which requires a per
to construct,alter,
x 4 0O improve,demolish,or repair any structure,prior to its issuance,also EIEC.CONTR. LIC. ELEC. /
DLL requires the applicant for such permit to file a signed statement that t4TW *WW�-, C G C_T-, TOTAL N 60 PERMIT TO
wm he is licensed pursuant to the provisions of the Contractor's License w— "G
HZa
Law(Chapter 9(commencing with Section 7000)ofDivision 3 of the
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢= $ the basis for the alleged exemption.Any violation of Section 7031.5 1 i STORIES TYPE CONSTR.
by any applicant for a'permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA-) 5.00
Oland more than five hundred dollars($500):):
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 4.00 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. 5.00
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 ' 5.00 SD.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA,SVSTEM-11NC.40UTLETS 6.00
ments are not intended or offered thistle.If,however,the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES -IND CON PB Omar
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30,00
❑ 1,"as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply -to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS'-OVER 5(EA.) 1,00
contracts for such projects with a contractors)licensed pursuant to SANITAR VSTORM EA200ft 1000
- - . .
the Contractor's License Law. SEWER / TRACT N0, PARCEL NO.
❑' I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT .6.00
reason
Owner Date WATER SYSTEM - 5.00
ACC.GATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 ,
I hereby affirm that I have a certificate of consent to self-insure, -
or a certificate of Workers Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.CJ. '
Policy No. Company
O ❑ Certified copy is hereby furnished. • FIRE SPRINK ENERGY T44
ZIV Certified copy is filed with the city inspection division.
p pcanl MISC. REFER TO ORD. y;❑ N Y ❑ N❑
PERMIT ISSUANCE 10,00 . FLOOD ZONE A.L.U.C.CERTIFICATE E EXEMPTION FROM WORKERS'
W _ COMPENSATION INSURANCE - PLG.CONTR. LIC.NO. I.G.P
Q. O (This section need not be completed if the permit is for one
TOTAL V❑ N❑ V ❑ N❑
:) Z hundred dollarS($100)or less.)
U O 1 certify that in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California. -
Do Date Applicant BUILDING
a ALTER OR ADD TO MECH. 5.00
. �. w NOTICE TO should become
If,after making this Certificate Compensation
Ex- _
F z emplion,you she L bor Code,subjecttoWorkers'Wrthwith comply with
qpp LIANCE 5.00 PLAN CHECK ,
provisions io the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked: '• AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=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,Civ.C,). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE), 4.00
% information is correct. I agree to comply with all city and county PLUMBING
! ordinances and state laws ing to building construction, and' BOILER-COMPI3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize re ntalive of this city to enter upon the 'BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above mentioned party for i ection purposes.
(We) agree save, Inde Ify and keep harmless the City of MISC.- REFER TO ORD.
Cup a Dust liabilitie Judgments, costs and expenses which CONST.TAX
in way against said City in consequence of the PERMIT ISSUANCE 10.00
ant - MECH.CONT. LIC.NO. MECH.
^1 ��.7 TOTAL TOTAL
ature of P11hant/Contractor Dale
OFFICE COPY