17486APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT Sgp^
I DING - ELECTRICAL- PLUMBING -MECHANICAL
/ p' tiPERMIT NUMBER
VA ` 17486
BUILDING
�/
OWNS
NAME
e D
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
Y
GATE OF APPLICATION
CDER CT
/ ,Lc.NO, /
UTLETS- SWITCHES -RECEP 10.00/1.00NA
LIGHTING FIXTURES .10.00/1.00
CO1TrA7kCTOA'sPPLIANCES-RESIDENTIAL
ADD BB(� f a/
PHDrvE �1//J
4.00
PANELS 10.00
ARCHITECT
OR
ENGINEER
LIC. No.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH. OR ENG.PERMIT
DOREss
SPECIAL CIRCUIT .00
VALIDATION
-,g
TEMP. METER OR POLE IN .00
ZIP
•' '. J. 0
tit
rU
nool SSTs L (\� r
1 -7 S�ST.k)[( .J�
MOTORS EEF ESCH.
SERVICE CHANG
0.00
LICENSED CONTRACTORS DECLARATION
.:IwR .
I hereby affirm that I am licensed Linder provisions Of Chapter 9
ISSUANCE DATE
(commencing with Section 7000) of Division 3 of the Businco,
(cense is in full force
License Cb{� Lie Nunr,T_4
Professions CoVONTI'BUILDER
BLDG.
ELECT.
❑
PLG. MECH,
❑
Dote �1 �r]�Contrmtor--�
�l
BUILDING PERMIT
DECLARATIOt.
I hereby uflinn that 1 am exempt from the Contractor s License
Law for the following reason. (Sec 7031.5, Businessand Professions
Code: Any city or counly which rec eires a permil to construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
INFORMATION
M LSC. - R ERT R
VALUATION
$/FT.
PERMIT I DANCE
0.00
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL
PERMIT TO
QTY. lii,LUMBING PE MIT FEE
1
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code), or thm he is exempt therefrom and
lire basis for the alleged exemption. Any violation of Section 7031.$
STORIES
TYPE CONSTR.
ALTER-DRAIN-WATER(EA.) 5.00
by any applicant for a permit subjects ore applicunt Loa civil penalty
' of not more than five hundred dollars (5500).1:
❑ 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
intended or offered for sale (Sec 7044, Business and professions
BACK F LOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
CodeThe 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 5.00
_sU. PT. FLOOR AREA
TOTALACREAGE
himself or through his own employees, provided that such improve-
mentsare nor mtendedoroirered for sale. IF, ha waver, tha building
GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or int-
prove for purpose of sale.).
❑ I, as owner of file property, an exclusively contracting with
,reeled contractors to Construct the project (Sec. 7044, Business
GAS - EA. SYSTEM -OVER 4 IEA.) 2.00
BUILDING USE
RES IND CON PB Other
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
and Professions Code:'fhe Contractor's License Law does nor apply
to an owner of property who builds or improves thereon. and who
LAWN SPRINKLERS - OV ER 5 (EA.) 1.00
contracts for such projects with a conlmctods) licensed pursuant to
the Contractor's License Law.
SEWER -SAN ITAR V -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 6.00
❑ lam exempt under Sec. ,B.&P.C. tilt this
reason
Owner Date
WATER SYSTEM 5.00
ACC.DATE
ACC. FILE NO,
G�Q OR) RRS''COOMPr}N CI E LrA TI
WATER TREATING EQUIP. 5.00
111:ID11 )' atlll'11iY1tj11110R a rt lel 11 elm.ve rift t[II-in are.
or a certil irate of Workers' Compuns'{�tion In anther, x cercied
ZONING
ENG. SITE NO.
-
copy thereof (Sec. 3800, Lab.0////,,♦ /1 p)r
1'olicy NO. CampanyW', /1l:/1-
❑ Certified copy is hereby urnlshed.FIRESPRINK
ElCertified copy is tiled with the city nspection division.
y[J NE]
ENERGY T 24
YE] NE]APPlicant
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.00
FLOOD ZONE
AT.U.G.
CERT'IFICA'rE OF [AHMPITO,N FROM WORKERS'
PLG. CONTR. LIC. NO.
PLG.
TOTAL
00M1TNSATION INSURANCE
(bilis section need not be colnplCtcd if the prunit is for one
Y❑ N❑
Y❑ N❑
CITY. MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollen (S 100) nr less I
I certify that in the performance of the work for which this per
Lou is issued, I shall not employ any person in any manner so as to
become subject m the Workers' Cmnpmuation Laws Lf"'fo..ia
Date Applicant
NOTICIi 'IU APPLICAN'C, IL after making this Curti( cute of Ex-
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked
BUILDING
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
FEE
�b`O�
AIR HANDLING UNIT (TO IOPMC.F.M.) 4.00
AIRHANDLING UNIT(OVER 10=C.F.M.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.).
HEATING UNIT TO 100,000 B.T.U.) 8.00
HEATI NG UN IT (OVER 100,000 B.T.U.)9.50
ELECTRIC
Lender's Name
Lender's Address
I certify that l have read this application and state that the above
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
briefly aurhorice representatives of this city to enter upon the
above-mentioned property for inspection purposes.
ree to save, moily and keep farndcss the City of
against Nabi ie 'udgm fs, costs aL'enes which
Dart j
wayacct a 'nst d City ' cunseyuence o thealj�
K'StApplicant/ ontmetor to l
VENTILATION FAN (SINGLE) 4.00
PLUMBING
BOILER -COMP 13 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
MLSC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 10.00 �11usp
JH. CONT. LIC. NO.
1! ` 7 y
'Ar
MECWf
TA I�. �
TOTAL
� 0fl
OFFICE COPY