C7265 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES.- USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
HOLDING APPLICATION & PERMIT 7265
A.0REa5
/G �� BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
L l..l Are In,pP Orly-� �y �yG�ry C' LANG CK VALIDATION
OWNER'S rF` r �("YS'Sag:4 Y`:
NAME �^/I Q�/�/yy� G7Y1�' 1�,P EiIE�CTgRaIrCY'PEyR1.M IT
l l ll IJ P ONE / '�i'V W db IIQ-4I4 .h�IJ�'�If fYvr'l1'?Nl4'L'a4''� .L wM� MS1{f4-f+1
CONTRACTOR'S UTLETS-SWITCHES RECEP 5.00/1,00
NAME
uc.uo. LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 5,00 DATE OF APPLICATION
ARCHITECT6,08 PLANGHECK P.C.NO.
OR SIGNS
ENGINEER
uc NO SIGNS TRANS. 3.00
ADDR.SS ENO, SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH. )
AODH ESS
SERVICE CHANGE 1 OP6
r o O LICENSED CONTRACTORS DECLARATION
ec o. 1 hereby affirm that I am licensed under provisions of Chapter 9ISSUANCE DATE
w C m (commencing with Section 7000)of Division 3 of the Business and ELECT. PLG. MECH.
H w Z Professions Code,and my license is in full force and effect. PY
El 1:1 1:1o,�- License Class Lic.Number
-
0
r Date Contractor
m `¢ ¢ OWNER-BUILDER DECLARATION I,W�u�t",'��BU,ILDING'�PERMIT
o d " MISC.- REFER TO ORD k'.?9x dINFORMAT,ION�_.
o I hereby affirm that I am exempt from the Contractor's License PM
TON S/FT.
u o a Law for the following reason.(Sec.7031.5.Busioemm d Professions PERMIT ISSUANCE 6.00
Code:Anycityorcounly which requiresa permit to construct,alter.
`-
at a improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. UC.NO. ELEC.
-Cr LL requires the applicant for such permit to file a signed statement that TOTAL _P"IT TO
- w$ he is licensed pursuant to the provisions of the Contractors License +;q y e y w's s ,SL`J r'4 -�:` j�/QO�
HZ¢ Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe "?� +I�' ?Q4iP6UM81NG PERre 1 MIT y+-. FEEn:
izo the basisiness alleged exemions etion.tAny hiolalion ofSection
70J41n5 ',!'r:• �� 4S1.s ."`j/`w''.*'+skE�r - 's' f�'st'{: `,i�,Y+s}�'� b
exempte is RT ".k 5 T"tea 6 IBD TYPE CONSTR.
o g 0
ate _ by any applicant fora permit dollars(S500).):
0).): ant coacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(my em:
❑ Las owner at the property,or my employees with wages as BACKFLOW PROTECT.DEVICE 2.00 DEC.GROUP REB.UNITS
their sole compensation,will(S the work,and the and Professions
is not
intended or offered for sale (Sec. do Business and Professions DRAINS-FLOOR,ROOF,AR EA,CON D. 4.00
Code The Contractor's impose Law does not apply To an owner of
property who builds or improves Thereon,and who does such work FIXTURES-PER TRAP 4.00 $o.Fr.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
OUTLETS 4.00
mHsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-1 INC.4
m
or improvement is sold within one year of Completion,the owner- GAS-EASYSTEM-OVER 4 (Eq.) 1.00 BUILDING USE
builder will have the burden of p .roving that he did not build or im- RES IND D CON vB Omer
prove for purpose of mit.). INDUSTRIAL WASTE INTER. 2000.
❑ I,as owner of the property.am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law dues not apply
to an owner of property who builds or improves(hereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractorls)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ la ex under Sec. .B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Uately WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
W'ORKERS'COMPENSAT ION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a Certificate ofcousenl to Self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800.Lah.C.).
Policy No. Company
O ❑ Certified ropy ishcreby furnished. FIRE SPRINK ENERGY T-24
z Z ❑ Certified copy is Bled with the City inspection division. MISC.- REFER TO ORO. y❑ No Y ❑ No
O Applicant
CC CERTIFICATE OF IiXIiMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
ELI > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. v❑ NE] v❑ N[]CL 0 (This section need not be completed If lire permit is for one TOTAL
Z) Z hundred dollars IS TDO)or IeSS) i!' • T -w r 's. , ( 'n-Ya;V. kT, - -A��a+-...�1�+y�i��
U I certify that in the performance of the work for which thins per bT.,-r. I 4- L'- a r ,V ^>'u o - % ye FEE SUMMAF , I F
O�T?V'',>'( wj MECHANICAVYERMIT£ n3 FEE. A- ."y"f..,5,...a....�- v:�+FJq:�
LL mil is U arine I
heromi subeecT loall not chH Work�rs'Coloy m person
utionnLaws of Caldo nM 10
;iffis tl;n' i'' ��� kRK" "
pen q
O ED Dane Applicant ALTER OR ADD TO MECH. 4.00 BUILDING Xs
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z mnption,you should become subject to the workers'Compensation APPLIANCE 4.00 FEE CHECK
ptwisions of the Labor Code, you must forthwith comply with --
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C,F.M.) 3.00
CONSTRUCTION LENDING AGENCY R
IR HANDLING UNIT(OVER IQDOOC-EM.) 5.00 SEISMIC FEE sa
I hereby afFi m that there is a construction lending agency forXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this
permit is issued(Sec. EATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ.C.).
Lenders Name EATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that 1 have read this application and state that the above ENTI LATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and County PLUMBING
ordinances and state laws relating to building construction, andOILER-COMP 13H.P.or 100,0008.T.U.) 4.00hereby authorize representatives of this city Io emer upon theOILER-COMP Over 100,000 BTUI SEE FEE SCH, MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save. indemnify and keep harmless the City DI MISC.- REFER TO ORD.
Cup tion against liabilities,judgments. Costs and expenses which CONST.TAX
tin
Ra m any way accrue against slid City in consequence f the PERMIT ISSUANCE 3.00
gm g Ont. MECH.CONT. LIC.NO. MECN. (:.Nry"1;=,.j11"I_P y=Je
J S
Ucy Q 1 %, �
PTOTAL w>:ilOT 4t,
Signature c APPlicantlContraclor 111ale I
' OFFICE COPY