3159 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTI FICPERMIT NUMBER
BUILDMG1VY -Z.4,3 APPLICATION & PEIRT _A3159
AOD ss
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWN R' s PLAN CHECK VALIDATION
NAMEJ^
WE 4 OTY. ELECTRIC PERMIT FEE
NT
CONTW
ACTORS OUTLETS-SWITCHES-RECEP 5.00/1.00
�F
OV L Cvd Q uO No, (}f LIGHTING FIXTURES 5.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADDRESS �1 RwC
`G(J[/n/If f L{.- PHONE 36 -Yu PANELS 5.00 DATE OF APPLICATION
ARCHITECTSIGNS 600 PLAN CHECK FEE P.C.NO.
,
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIALCIRCUIT 5.00 PERMIT V41_IDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH. I V
ADDRESS
' SERVICE CHANGE 10.00 V\\1
o LICENSED CON TRACTORS DECLARA'I'[ON
ii w 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
a (commencing with ction 7000)of Division 3 of fl a Business and B U=ELECT. PLG. MECH.
F z Professions Code,a my license is in full for�Efl �(ecy. J7 ❑ ❑ ❑
Z o w - Licen Class Lic.Nmnber_ LL
Q zm r w Date-/6 ZL -kms-Contractor
SIC ¢ w 4 OWNER-BUILDER DECLA ATIO BUILDING PERMIT
R o d D MISC.- REFER TO ORD NFORMATION
I
w 3 LL I- I hereby affirin that I am exempt from the Contractors License VALUATION SIFT.
F u.o a Law for the following reason.(See.7031.5.Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct.alter,
Q Q¢ 2 Improve,demolish,or repair any structure',prior to Its Issuance,also ELEC. LIC.CONTH. NO. ELEC. U�.�y.J1
V o
0 LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
d w m he is licensed pursuant to tire provisions of the Contractor's License E...,
F z a Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 o Business and Professions Code)or that he is exempt Gmretron,and OTY. PLUMBING PERMIT 5 e V
r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applleaut to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars 155001.1:
❑ I,as owner of me property,or my employees with wages as BACK FLOW PROTECT-.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (See, 7044. Business and I'rofessians DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:"rhe Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who dues such work FIXTURES-PER TRAP 4.00 s0.FT.FLOOR AREA TOTAL ACREAGE
meat,l or through his own emred fors,provide)that such iso rove-
building
mems..not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4OUTLETS 4.00
40 or inhproventem is,sold within one year of completion,the owner. GAS-EASYSTEM-OVER 4 (EA.) 100 BUILDING USE
builder will have the burden of proving that he did not build or iso . .
- RES IND PB Other
prove Icor purpose of Sule.1. INDUSTRIAL WASTE INTER. 20.00 ❑ 1:11:1 El
I,as owner,of the Property'.an,eeclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESS o SPARCEL 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 cuntructono licensed phosuunt to
the Contractor's License Law. SEWER-SANITARY-STORM EA,200ft/8.00 TRACT NO. PARCEL NO.
❑ ions excnhpt under Sec.-.B.&PX..for this WATER HEATER W/VENT 4.00
rcxsan
Date Ownur WATER SYSTEM 4.00 Acc.DATE ACC.FILE NO,
WORK I.RS'COMPE NSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that 1 have a certificate of consent on wIf-insure, ZONING ENG.SITE NO,
or a cc,ftimte of Workers'Compensation Insumncu,or'u certified
copy thercof(Sec.3800,Lab C.1y �`-
Policy No, Com a ry.�7parpsJ_F✓ S2
O ❑ Ccr cdc y'is c, ylumishcd. FIRE BPRINK ENERGY TQ4
Z_ Z ❑ Ir
sop RAE d with the city inspection division. MISC.- REFER TO ORD.
App li ant _ V❑ N❑ V ❑ N❑
I' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
fY ; :kill° Ti OF I AX I N ION FROM WORKERS'
L J _ CON INSURANCE: PLG.CONTR. LIC NO. PLG. V❑ N❑ Y❑ N❑
CL (T section need not be completed if the permit is for one TOTAL
2 hundred dollars IS 100)or ICSS.)
'U O 1 certify that In Gro pelfonmunce of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
L.L H mit is issued,1 shall not employ any person in any manner so as to
Ow becmnc slhjemmthe Walkers'Compensation Laws of California. BUILDING / ✓(/�
Date Applicant ALTER OR ADD TO MECH. 4.00
} Go NOTICE 'TO APPLICANT If,after making this Certificate of Ex-
2 cmlumn,you should became sohjncl to the Worker.Compcnsatm, APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U suet,provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the perfornunce of the work for which this permit k Issued(Sec MICROFILM
3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certity that 1 havu read this application and'sons that the chose VENTILATION FAN (SINGLE) 3.00
•
inter...Aliun is ecorco.I e Lo comply with al`city tad county BOILER-COMM H.P.or 100,000 ETU.) 4.00 PLUMBING
ordinunees and 'Lute I relating to building construction, and
hereby orire rep entatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. - MECHANICAL
above m honed pr erly for inspection purposes.
e) gree to ve, indemnify and keep harmless the City of MISC.- REFER TO ORD.
C herr n again' labilitics,judgments, costs and expanses which PERMIT ISSUANCE 3.00 CONST.TAX
ay accrue against slid City in consequence of the
grant a f th' crmiL ✓ MECH.CONT. LIC.N0. MECH. /�
- <(o F TOTAL TOTAL v/J�
goutu fA icanllContractor Date ��:/
OFFICE COPY