2986 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
UPERMIT u
aDILDAPPLICATION & PE _T
BUILDING PROJECT I DEN71 FIC 8 (^
AOOR $$ J U 6
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
E 'S PLANCHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE
PHONE f
CONTcTORs UTLETS-SWITCHES-RECEP 5.00/1.00G�
NAIIW
uc.No. LIGHTING FIXTURES 5.00/1.00
roN RAcroRs APPLIANCES-RESIDENTIAL 4.003-6T J� / y
ADORE
Z �8 / IV PHONE PANELS 5.00 DATE OF APP CATION '`L
r\ 6,00 PLAN CHECK FEE
OORCHiTEDT (!/LUQ�/� '� SIGN$
ENGINEER
'E� rZ LIc.No. SIGNS TRANS. 3.00
ADDR.SS ErvG, SPECIAL CI RCQI7 5.00 PERMIT VALIDATION
i
ADDRESS
v AiR a4 LOO zlv EMP-METER OR POLE INS. 15.00
ADDRESS Ta LUS�? n/ Gam..? MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
O o LICENSED CONTRACTORS DECLARATION
a o u I hereby aflinn that 1 am licaswd under provisions of Chapter 9 ISSUANCE DATE
,HA a w (commencing with Section 7000)of Division 3 of the Business and ELECT. PLG. MECH.
H H z Professions Cede nJ my license is in full fur un IV.
edi T• � ❑ ❑
z O m - License 'lasy�yy�,_j� Lie.Number ']
o w t w Datc/-�,"� Con;/aclor;
P: 11CA C OQ_Nf.R-Il Uil-Ii R DECLARATION {tJ���{{(0�LG PERMIT
¢ w `u �INg(jf�1AATION
O I hereby affirm that 1 am exco t from the Contoctoh License MISC.- REFER TO ORD
w LL ' v, Y P VALUATION I $(FT.
H _ o a Law for the following reason.(Seo.7031,5,Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,alter,
¢ ¢¢ p improve,demolish.or repair any structure.prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC,
O 0 ocgmPv,the apphCant Vr Such fconit to IIle a Sl gm'.I,tatenlent that TOTAL PERMIT TO
wmU. he is licensed pursuant IN the provisions of the Contractor's License
F z t Law(Chapter 9(commencing with Section 7000)of Division 3 fthe
a Business and Professions Code)or that hu is exempt therefrom and CITY. PLUMBING PERMIT FEE
szo
¢ H$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n3 _ by any applicant for a permit subjects the applicant toacivil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars($500).):
Cl I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GHOUP 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. 4.00
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 4.00 so/.FT.FLLOORR AREA TOTAL ACREAGE
himself re through his own employees,prrvid eJ that such ibuildin I!/ J 09
mems are not intended or offered for sola If,however.s the building GAS-EA.SYSTEM-1 1NC.4 OUTLETS 4.00
or improvement is sold within one year of completion.the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of pouring Ilial he did not build or on' RES W D Ory PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ CC_❑ ❑ ❑
❑ d as owner of tie property'.he exclusively contracting with
licensed contractors Cod to iconstructe Contra the project(See. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL No.
and Professions Code: he Contractor's License l.nw does not wply
ho
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00 d
contracts for such projects with a conlraclorlsl licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam escmpl under sue. .B.&P.C.lira this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
woRlaiRS'CONPIiNSn'noN urc1.ARATION WATER TREATING EQUIP. 4.00
I Irereby of Drm that I have a Cerliftaale of consent to self-insure, ZONING ENG.SITE NO.
or a Certificate of Workers'Compensation Insurance or a certified
copy thereof(:.get.3800,Lab.C.l. I ��✓1 Ay Z,
Policy No. Company R•/
O ❑Certified Copy'iahereby'furnished. (y +�.Z. FIRE SPRINK ENERGY T-24
ZZ- 4s Certified y fled
wihtlryGlt itu'pebl ision. MISC.- REFER TO ORD. Y N❑ YX No
Applicant wlf- 'X-1 ('V S
F � PERMIT ISSUANCE 6.00 FLOOD ZONE
LU W CI:RTII'ICCOI IOIP EXEMPTION I'TINS PROM WURRIiRti'
lll7 COhll'ENSAI'IOh'INSURANCI$ PLG.CONTE. LIC.NO. PLG.
0. O ('Phis section need not be completed If the permit is for one - TOTAL Y❑ >
0 Z hundred dollars 1S 100)or less)
U O I certify that in tire performance of the work for which this per.PAPPLIANCE
CHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,1 shall not employ any person in any manner IT as to
O w become subject to the Workers'Compensation Laws of California.
a
Dutc Applicant DD TO MECH. 4.00 BUILDING S S
} m NOTICE TO APPLICANT: If,after making this Certificate of I
emption,you should become subject to the workers Compensation 4.00 PLAN CHECK
provisions at' the Labor Code, you most forthwith comply with FEE �KL
U such provisions or this permit shall be deemed revokcd. G UNIT(TO 10,000QF.M.) 3.00CONSTRUCTIONLENDINGAGENCY GUNIT(OVERIQOWC.EM.) 5.00 SEISMIC FEEI hereby affirm that tore is a em,,Rr lion lending agency tialOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name HEATI NG UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city'and county BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and stale laws Totaling to building construction, and
hereby authorize representatives of this city le enter upon the BOILER-COMP lower 100,000BTUISEE FEESCH. MECHANICAL
above-mentioned property(oy speclims purpoxs.
(We) gree to save, in filo fy nd keep harmless t e City of MISC.- REFER TO ORD.
-pert o ugui 'I liabilif s,��l1udgl )n, costs and expcnsus which PERMIT ISSUANCE 3.00 CONST.TAX
may i an ay uceru u4ains City in conseyuenee of the
Wgo tis r sit. MECH.CONT. LIC.NO. MECH. 70
I ,2-+/gs TOTAL TOTAL C/�
meof pelican ontruclnr Date)
OFFICE COPY