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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING -ELECTRICAL -PLUMBING -MECHANICAL
PERMITNUMBER
O
rC Vl 0
BUILDING
AOOREss ,{�J
- OS �UE
OWNER'S
NAME
04(� ///^�'�/^� ••//J��J
PP� l�.✓MPU 7 HONE
QTY . ELECTRIC PERMIT .FEE
PLAN CHECK VALIDATION
CONTRACTORS
N ME
UTLETS- SWITCHES -RECEP 5.00/1.00
U C.
DATE OF APPLICATION
ILIGHTING FIXTURES 5.00/1.00
CONTRACTORS
AO REss
s' V1,6W 'NONE o ? aYCO
PPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
ARCHITECT Q/'`
OR /1 C�VJOLJ•
ENCINEEnle LIC. NO.
SIGNS 6
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH, OR ENG.
ADDRESS
SPECIALCIRCUIT 5.00
PERMIT VALIDATION
OCT�
h `�Y� O
rEMP. METER OR POLE INS. 15.00
APPLICANT'S
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am focused under provisions of Chapter 9
A., JSSUANCE DATE
(commencing with Section 7000) of Division 3 of the Business and
Professio / my license is in full fortr/1Im 113 /
Lictnsy-{�P / Li c. Numll felt-� G J _7
Date Lo t Contractor �y��->�GG /�QlA
OWNIiR-BUILDER DECLARATION
I hereby collo that 1 am exempt from the Contractor's License
Law for (he followingreason. ( Sec. sires a,ermit tocnd Professions
Code: Any city or, ounty whiny structure permit to construct, also
improve, demolish, of repair any structure, prior its e; also
E Q IR G. MECH.
❑ O I'r-I
LJ
BUILDING
PERMIT
t
MISC. -' REFER TO ORD
vALUATIOry
E/FT.
PERMIT ISSUANCE 6.00
ELEC. CONTR. LIC. NO'
n aterr
requires the applicant for tiro permit to file a signed statement that
he is licensed pursuant n in provisions of 700 Contractor's License
Law (Chapter Precommtncimic) ,, Section iseseuft t1,ercfrohh ,nd
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5
-
TELEC
TOTAL
OTAL
PERMIT T
14/'%�iQ/QIQ G-TNJOLE-
QTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
ALTER -DRAIN VENT -WATER IEA.) 4.00
by any applicant for a permit subjects the applicant to a civil penalty
of nor more than five hundred dollars (SSOOy):
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will Jo the work, and the structure is not
intended or offered for sale (Ste. 7044, Business and Professions
IBACK FLOW PROTECT. DEVICE 2.00
OCG. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 4.00
Code: 'fle Contractor's License Law docs not apply to an owner of
property who builds or Improves thereon, and who does such work
FIXTURES - PER TRAP 4.00
SO.FT.FLOOR AREA
TOTAL ACREAGE
himself or through his own employees, providedthat such improve -
.cut, are nut intended or offered for sale. If, however, the building
GAS - EA. SYSTEM -1 INC.4 OUTLETS 4.00
Or imploven ent is sold within one year of completion, the owner.
builder will have the burden of proving that he did not build or ire-
prove for purpose ofsdle.).
❑ I, as owner of the prupctly, am exclusively contracting with
licensed contractors to c nxtruet the project (Sec. 7044, Business
GAS - EA. SYSTEM - OVER 4 (EA.) 1.00
BUILDING USE
RES IND CON PS Other
INDUSTRIAL WASTE INTER. - 20.00
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
ASSESSORSPARCEL NO.
and Professions Code: I he Contractor's License Law does not amply
to an owner of property who builds or improves thereon, and who
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contmels forsuch projects with a contrachodO licensed pursuant to
the Cntractors License Law.
C0
SEWER-SANITARY-STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 4.00
❑ tum exempt under Sec. .B.&P.C. far this
reason
Owner Date
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO.
' WORK ERS'COMPENSATION DECLARATION
WATER TREATING EQUIP. 4.00
I hereby of firm that I have a certificate of cmtxmt 10 self -insure.
or a certificate of Workers' Coy punsation Insurance. or a certified
copy thereOq((yy$$e`� i9�ypWWW.VI.
Policy Nn3a w-�L'Tnrp y C�If_Ce�p•
❑ CL,:d Isbcrcby mishe
❑ Ccrll c c tc ith 'ty in, PecG, Aivi "
Applicant_ .
TONING
ENG. SITE NO.
,
FIRESPRINK
Y E) N�
ENERGY T 24
y E) N�
,MISC. - REFER TO ORD.
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.U.C.
CERTIF'ICAT [i01' EXEMPTION FROM WORKERS'
PLG. CONTR. LIC. NO.PLG.
TOTAL
COMPENSWION INSURANCE
Il his section need not he completed if the permit is for mm
Y❑ NE]
V[] N�
OTV. MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars IS 100) or less.)
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
Dale APPlic-ot
NOl'ICF-'IU APPLICANT': If, after making this Certificate of Fix-
emption, you should become subject to the Workers' Compensation
provisions of the Labor Coda you must forthwith comply with
such provisions or this permit shall be deemed revoked.
BUILDINGzo,
l7 �.3
ALTER OR ADD TO MECH. 4.00
APPLIANCE 4.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO JOSMWC.F.M.) 3.00
AIR HANDLING UNIT (OVER 10JMC.EM.)5.00
SEISMIC FEE
a�
CONSTRUCTION LENDING AGENCY.
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
I hereby affirm that there is a construction lending agency for
the perl'onnaneC of the work for which this permit is issued (Sec.
3097, Civ.C.).
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UNIT (OV ER 100,000 B.T.U.)7.50
ELECTRIC
Lender's Name
Lender's Address
I certify that I 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
VENTILATION FAN (SINGLE) 3.00
PLUMBING
BOILER-COMP13 H.P. or 100,000 B.T. U.) 4.00
801 LER-COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this City to enter upon the
above-mentioned property I'or inspection purposes.
(We) agree to save, indemnify and keep harmless the City of
C against liabilities, judgments, casts and expenses which
n yin I way ac- against said City in consequence of the
anlinI' cr
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 3.00
MECH. CONT. LIC, NO,
MECH.
OTAL
TOTAL
�16f !!I-
to', of ApplicamlCantrpclor e
OFFICE COPY