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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 " _