3067 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT•PEN'ON
BUILDING PE MBER
UILDING PROJECT IDENTIFICATION .APPLICATION & PERMIT I�{ /h� 7
BUILDING -ELECTRICAL-PLUMBING -MECHANICAL V O V 1 -
OWNER - - - - --`- -- "' - PLAN CHECK VALIDATION.'•
QTY. ELECTRIC PERMIT w FEE
CSM
NAMfinc RS - J� OUTLETS -SWITCHES-RECEP 5.00/1.00
F Lia LIGHTING'FIXTURES 5.00/1.00 .
'I A �70NTRACTORS ®,pn �/P�� '- APPLIANCES-RESIDENTIAL 4.00
�B��� SGe{� • IITOIIE PANELS 5.00 DATE OF APPLICATION
Sc'SO FIRST STREET _ PLAN CHECK FEE P.C.NO.
FF��yyrF���� !" w� -'SIGNS' 6.00
a/i1Y"r�Ni' 0 SIGNS TRANS. 3400
ARCR,Q468) 297-8107 SPECIALCIRCUIT - 5.00 PERMIT VALIDATION
'ARCHES (,�V�
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS ] MOTORS SEE FEE SCH.
ADDRESS
19
SERVICE'CHANGE 10.00 /r/�
S o "LICENSED CONTRACTORS DECLARATION 1g d
a i w I hereby affirm that am licensed under provisions of Chapter 9 - ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
�i ¢ BLDG- ELECT-. PLG.' MECH.
H w i Professions e,a license is in full f s eft ❑ ❑ ❑
z out - License ClaasLin.Number - '- - -• - ..
- Date Contractor`��
¢ a w ¢ OWNER-BUILDER DECLARATION BUILDING PERMIT'
ED A u INFORMATION
wB.n w 'I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
B. 0¢ Law for the following reason(Sec.703 L5;Business and Professions VALUATION $/FT.
.,3 Code Any city or county which requiresa permilto construct,alter, PERMIT ISSUANCE 6.00
¢ 2¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. -
G u he is licensed pursuant to the provisions Of the Contractor's License requires the applicanLfor such permit to file a signed statement flat -, TOTAL PERMIT TO
o, w _
FZQ. Law(Chapter 9(commencing with Section 7000)of Division 3_ofthe
i O Business and Professions Code)Or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
It r m sthe basis forahe alleged exemption.Any violation a]Section 7031.5' STORIES TYPE'CONSTR.
S.S. - by any applicant for a permit subjects the applicant to a civil penalty
ofnot more than five hundred dollars(8500).): ALTER-DRAIN&VENT-WATER (EAJ 4.00
❑ I,as owner Of the property,or my employees with wages as BACK FLOW PROTECT.-DEVICE 2.00 Occ.GROUP RES.UNITS
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[hereon,and who does such work FIXTURES-PER TRAP 4.00 50.FT.FLOOR AREA TOTAL ACREAGE
himselLor through his Own employees,provided that such improve-
mends are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 1 PIC.4 OUTLETS 4.00
or improvement issoldwithin one year of completion, the owner- GAS EASYSTEM OVER 4 (EA) 1.00 BUILDING USE
builder will have the burden of proving that h - . - .
e did not build or In- RES IND - CON PB Omer'.
prove for purpose of Sale.). - INDUSTRIAL WASTE INTER. 2000
❑ I,as owner of the,property,am .
exclusively contracting with El ❑ ❑ ❑ El
licensedcontractorsto construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL N0.
and Prnfessmns 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 '
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT No. PARCEL NO.
❑ 1 am exempt Under Sec. '" B,&P.C.for this WATER HEATER W/VENT 4.0
reason'
., Date - Owner WATER SYSTEM - 4.00 .ACC.DATE ACC.FILE N0,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insuran •,ora cetlifie
w of b .1
P
Q ❑ Certified copy is hereby urnishe FIRE SPRINK ENERGYT24
zp plicanttifte p is fled withe. R ns ec Inn division. MISC.- REFER TO ORD. yN
m PERMIT ISSUANCE 60 FLOOD ZONE v A❑ N
G ❑
CC ',CERTIFICATE OF EXEMPTION FROM RKERS' '
LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This snetidn need'not be completed if the,permit Is for one IOTA /� 'V❑ NE]
❑ Y❑ N❑
2 In nm red dollars IS 100)or I.S)
U O I certify that in the performance at 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 a,m
ED become subject to the Workers'Compensation Laws of California.
y Date' ApplicantALTER OR ADD TO MECH. 4.00 BUILDING
} h NOTICE TO APPLICANT: If,after making this Certificate of Ex-
f- ? 'emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
-provisions of the Labor Code, you must forthwith comply with FEE
O such provisions or this permit shall be deemed.revoked AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY FAIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is'a constnmtion lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT�(TO 100,000 B.T.U.) 4.00
Lender's Name . . H EATING UNIT(OVER 100,000 B.T.0-)7.50 ELECTRIC
Lender's Address
I certify.that I have read this application and state that the abate VENTILATION FAN (SINGLE) - 3.00 -
mformatinn is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building constnmtian, and BOILER-COIL I3 H.P.or100,000B.T.U.) 4.00
hereby authorize representatives of this city [o enter upon the BOILER-COMP (Over,100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes. _
(We) agree to save, indemnify and keep harmless the City of MISC:- REFER TO ORD. -
Cuper.LED against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
in y sea accrue against said City 'n consequence of the
gr tip f ih' Trott. MECH,CONT, LIC.NO. MECH.
• TOTAL TOTAL
ig re App(cant/ ontrac[or e "
OFFICE COPY " _