17339 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION ,PERMIT NUMBER
BouLOING APPLICATION & PERMIT 17339
ADDRESS U flQ//� N �
/O C,oO /, BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME TY. ELECTRIC PERMIT FEE
l l�N r«orvE [767~L'T(,+
CONTRACTOR
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
l'
LIC.No, LIGHTING FIXTURES 10.00/1.00
CDDTRASCTon's
RESS PPLIANCES-RESIDENTIAL 4.00
ON
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 2000 PLAN CHECK FEE P.C.NO.
on .
ENGINEER
Llc.NO, SIGNS TRANS. 3.00
ADD Ess ENG' SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
zlv ITEMP.METER OR POLE INS. 20.00 O
APPLICANTS /l' ]oA rA/I� N n /'1� MOTORS '^SEE FEE SCH.
ADDR s V-f V )4V 11 P
/ SERVICE CHANGE 20.00 p � ,
o o LICENSED CONTRACTORS DECLARATION DV4vTo SIJ <_1
a v U I hereby a10nn that 1 at,,licensed colder provisions of Chaplet 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Rosiness and BLDG. ELECT, PLG. MECH.
rn i Professions Code,and my license is in full force and effect 1:1 ❑ 0
-zo 0 m o License Class Lic.Number
Date Contractor
P, y s ' - BUILDING PERMIT
c, M4 OWNER-BUILDER DECLARATION INFORMATION
wo wi - MISC.- REFER TO ORD
3 LL m I hereby affirm that I am exempt from the Contractor's License
u o 4 Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
ry Code:Any city orcomrty which requires a permit to construct,alter,
Q 2 G inmrove,demolish,or repair any structure,prior it)its issuance,also ELEC.CONTR. LIC.NO. ELEC. cty
-
- o ¢ requires the applicant for such permit to file a sitttued statement that TOTAL PERMIT TO
A w es u he is licensed Pursuant to the provisions of the Contractor's License //yyam�``II
Hzi Law(Chapter 9(commencing with Section 7000)ofEwision 3 of the PA [� L.LJXIE
- 4 Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
c r o the basis fur the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
Lu
by any applicant for a permit subjects me applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
or not more than five hundred dollars($500),)i
❑ 1,as owner of the property,or my employees with wages as BACK FLOW 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 on owner of
Property who build,Or Int prove,lheRon,and who dnCS Such work FIXTURES-PER TRAP 5.00 SQ FT.FLOOR AREA TOTALACREAGE
himself re through his own employees,provided that such imprme-
memsarenorintendedoroffereoyees, moved that such
building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00 210 yarY
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BU LDING USE
builder will have the burden of proving that he did not build or ins- RES IND CON PB Omer
pX for purpossol
e pf e .). INDUSTRIAL WASTE INTER. 30.00 1:1 1:1 ❑ ❑ ❑
,el I,as owner of the property,am exclusively contracting with
licemm
nud cootcrs to cotr
nsuct the project(Sec 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:l'he Contractor's License Law does not apply
to an owner of property who builds or improves diction,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such cprojects with a contractor(s)licensed pursuant m SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Cads fo su License Low.
❑ taco exempt under Sec. .B.SP.C.fur Deis WATER HEATER W/VENT 6.00
reason
owner Date 3f3l WATER SYSTEM 5.00 ACC.OATS ACC.FILE NO.
WORK ERS'COMI)ENSAT10N DECLARA'T'ION " WATER TREATING EQUIP. 5.00
1 hereby affum 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 mereof(Sec.3800.Lab.C.).
Policy No. Company
0 ❑ Certified copy is hereby fumished, hi FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is Fled wish the city inspection division. MISC.- REFER TO ORD.
O Applicant V C] N❑ V ❑ N❑
CC W CERTIFICATE OP EXEMPTION I7ROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LL > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CLO TOTAL V❑ N❑ Y ❑ N❑
fdre section sed not be nmpleR•d if the pcnnrt is for one
'0Z hundred dollars(n be orro.J
LL O I certify that h the Performance of person
work for which this Per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,e I shall enot W employ any person in any manner or as m
become subject to the Woekers'Compensation Laws of Californio.
0 w Data Applicant ALTER OR ADD TO MECH. 5.00 BUILDING __
} N NOl'ICE TO APPLICANT: If,alter making this Certificate of Ex-
F-. ? Lrop,ion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK �7 30
provisions of the Labor Code. you must forthwith comply with FEE [,4
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONSTRUCT ION 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 penni(is Issued(Sec. MICROFILM
"A",Cos
.C.l. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Nonhc
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that I have read,his application and slate that Thu abme VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city anJ county PLUMBING
ordinances and state laws relating to builJing construction, anJ BOILER-COMP(3 H.P.or100,000B.T.U.) 6.00
hereby aufhorim representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU(SEE FEE SCH. MECHANICAL
above-mentioned property I'or inspection purposes.
(We) agree to save, indemnify and keep harmless the City of misc.- REFER TO ORD.
upertmo attains( liabilities,judgments, costs and expenses which CONST.TAX
PERMIT ISSUANCE 10.00
ay in any way accrue against said City in consequence of the
con ng of this permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
• 7�r�D
` S g lure o1 Ap Imam/Contras or Dadc l-
I OFFICE COPY