09740 ARPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
13U LDI NG PROJECT IDENTIFICATION PERMIT
(NUMBER
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BUILDINGADDRESS APPLICATION & PERMIT 091 `FO
OdLoldj!
ADDRESS
L1 ?111LDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
OTY. ELECTRIC PERMIT FEE
HONF
CONTRACTOR
A UTLETS-SWITCHES-RECEP 10.00/1.00
NE
uc.ry �
LIGHTING FIXTURES 10.00/1.00
aoo ess TOR %,APPLIANCES-RESIDENTIAL 4.00
PHONE W+ PANELS 10.00 DATE OF APPLICATION
PRLHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO, SIGNS TRANS. 3.00
AHCH.off ENG. SPECIAL CIRCUIT 5.00 PERMIT VALI DATION
ADDRESS
ZIP rrEMP.METER OR POLE INS. 20.00
ADDRESS rS MOTORS SEE FEE SCH.
ADDRESS
et ISERVICE CHANGE 20.00 C/��J �^
wo 0 0_ LICK CONT RACFORS DECLARATION TEMP.POLE 30.00
r FF
a v U I hereby aflirm that 1 um licensed under provisions of Chapter 9 ISSUANCE DATE
w<m (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
FNz Professions C d• a d I is in lull for • ffe,ILAS..
z o m - Licce •Clas +�Lic.Number( ❑ ❑ ❑
9 z H w Date Contractor
a y BUILDING PERMIT
¢ ¢w¢ OWNER-BUILDER DECLARATION INFORMATION
oaU MISC.- REFER TO ORD
A ; u w 1 Eemby affirm that I am exempt from the Contractor's License VALUATION S/FT.
H LL o Q Luw(or the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
2 Z <40 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- DLL requires the applicant for such permit to file a signed ostcmcut that TOTAL MPERMITT
K
$ he is licensed pursuant to the provisions of the Contractor's License
HiQ Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
E 4 O Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢H$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a; by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($5001):
❑ I,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 .It (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
. himself or through his own employees,provided ev such improve-
mcuts it mselfonollnlended hhisorofferedforsarovideo Iliatsthe building GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner. GAS-EASYSTEM-OVER 4 IEA) 200 BUILDING USE
builder will have the huNen of proving that h . . .
e did not build or int- RES IND DON Pe Omer
prove for purpose of salt.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of the properly,am exclusively contracting with El F-1 ❑ F-1 El
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs 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 u conlraclor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WO cERS'COMPGNSA'Ff _ LARATI N WATER TREATING EQUIP. 5.00
I hereby a(fum That 1 have a ter fat of consent o selGinsun'. ZONING
U r a certif etc of Workeri Com i n an r� crt l d ENG.SITE N0.
copyther f(Sec.38 Lub. a
Policy No. or -
O ❑ Ccni 11 rcFIRE SPRINK ENERGY T-24
Z Z ❑ CCNII"cd c with t I. in I I division. MISC.- REFER TO ORD. v ❑ N❑ v ❑ No
APpllcxnl
CCT / PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.UC.
Lu - Cfi R1'I JCCOVIPE I AX 101,1 ION I' ORKIiRS'
W >_ COMPENSAT'ION INS i PLG.CONTR, LIC.NO. PLG.
d O '1'1'his section need not he completer if the permit is lin one TOTAL Y❑ N❑ Y ❑ IN
Z) 2 bondned doll...IS 100)or less.)
U O 1 certify that in the performance of the work for which this per OTY. MECHANICA&Ikl 6LT FEE FEE SUMMARY
LL F nlit is issued,I shall not employ any person m any manner so us to f'l► Vv
O LU becmnoaubect to lire Workers'CHTT ion Laws of California BUILDING
Dale ApplicantD. ALTER OR ADD TO MECH. 5.00 S'
} On NO"FICIi TO,APPLICANT': If,after making this Certificate of Ex- r
? eruption,you should become subject m the Workers'Compensation APPLIANCE U, 19bti 5.00 PLAN CHECK
Provisions of lite Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000 GF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT CIftF00WAMY 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance u(tj rk for which this permit is issued(Sec. MICROFILM
3097,Civ.C.l. ��A ��wJ j/e/� HEATING UNIT(TO 100,000 B.T.U.) B.00
Lender's Name G.+-/�//Ne/ LLY HEATING UNIT(OVER 100,0008.T.U.)9.50 ELECTRIC
Lender's Address
I certif 's application' state that the above VENTILATION FAN (SINGLE) 4.00
inl'or on is correct. I agree to c y with II city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
mance. and vont laws rel g t'O buildin construction, and
mrchy
all
thoriee representa ' es of this city to enter upon the BOILER-COMP (Over 100,000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned property r inspection pur ses.
(We) agrVwaye
' mnify and k harmless the City of MISC.- REFER TO ORD.
Crlino aes 'uJ cots uses my�expenxe.which CONST.TAX
may again seri ity in c6pSequence of lite PERMIT ISSUANCE 10.00granlln f t MECH.CONT. LIC.NO. MECH.
eA
t re o A ma
s TOTAL��•�D TOTAL
:for Dale
OFFICE COPY
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