17407 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BDILOINc
APPLICATION f 7407
ADDRESS Mc ,9 I'J J
(• a BUILDING- ELECTRICAL-PWMBING-MECHANICAL r
OWNER'S PLAN CHECK VALIDATION
NAME DTV. ELECTRIC PERMIT FEE
I l" C_v1,11VOfp NA PHONE
\- ONTRAC VONSUTLE7S-SWITCHES-RECEP 10.00/1.00
NAME _
• Q DYI s LIC.No. JG0,6 LIGHTI NG FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00 `
ADDRESS rraa 3/A�E
��R ' PHOrvE - 1/� PANELS 10.00 OF APPLI ATION
ARCHITECT •NMy PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDR.SS Ervc' SPECIAL CIRCUIT 5.00 PERMIT VAL ON
ADDRESS �j�/
ZIP EMP.METER OR POLE INS. 20.00 3 1
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
76SERVICE CHANGE 20.00 J 0e vtToit V-c
Oai
ATIO
F o O LICENSEE)CONTRACTORS DECLARN
a u w I hereby affirm that 1 mn licensed ander provisions of Chapter 9 `•,+ ISSUANCE DATE
l-Q N (comnnenemg with Section 7000)of Division 3 of the Business and 1. •e„�- BLDG. ELECT, PLG. MECH.
H se
Do,
Profesxions Code d I licenIs in fullrce fond effect. ,�Fy ❑
Z D a- License Class _ Lie Nunhherl� 'S�p08 ❑ ❑
D H w Uate_6 344/74 Contractor
a xBUILDING PERMIT
aw OWNER-BUILDER DECLARATION INFORMATION
X 3 TU.w I hereby affirm that 1 am exempt from the Contractor' MISC. S/FT.
Contractor',License .- REF TO OR
VALUATION
H LLmg Law for the following reason.(See.703 I.S.Businessund Professions PERMIT ISSUANCE 10.00 �dOa ,o
Code:Any city or cotmly which rerylres a penult to crmstruCL alter.
Qto Q O improve,demolish,Or repair any slruc1ure,prior to its sleall",also ELEC.CONTR. LIC.NO. ELEC.
O is requires the is for such Permit tO file a signed statement first TOTAL
A PERMIT TO
wbe is licensed pursuant to the provisions of the Contractors License
ou ¢ aLaw(Chapter 9(connmencingwith Section 700(1of Uivlsion, "'the
4 D Business and Professions Code)or that he is exempt Ihereffom and DTV. PLUM13ING PERMIT FEE �-
¢H o the basis for the alleged exemption.Any violation of Seel on
7031 $ STORI vPE CONSTR.
n; L by any applicant for a permit subjects lire applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
Of not more than five hundred dotlurs(S5001.):
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 DCC.GROUP RES.UNITS
their sulc compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Colic The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SG.IT.FLOW AREA TOTAL ACREAGE
+: himself or through his own employees'provided
If,however,the huilJing provid ed(fiat such improve- GAS-EA.SYSTEM-i INC.40UTLETS 6.00
t menus are not intended or offered for
or improvement is sold within one year of completion,the owner GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILOING USE
builder will have the burden of proving that be did nml build or inn- RES IND CON Pe Other
prove for purpose of sate.). INDUSTRIAL WASTE INTER. 30.00
O 1,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. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who wilds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.I 1.00
contracts for such project w' I a contrectots)licensed pursuant to
the Contractor's License .a SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ tum exempt end 5c. .B.&P.C.for flus WATER HEATER W/VENT 6.00
reason _
Owner Dam WATER SYSTEM 5. PCC.DATE ACC.FILE NO.
WORK F-RS' ( PENSAI'ION DECLARA'T'ION WATE TREATING EO IP. 5.
I hereby aifirra that I have a certificate of cnrsent to self-more. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insumnee,or a certified 11 -
copy thereof ISee.3900,Lab.C.).
Policy No.-C..Pppy
O ❑ Certified "sire h yfurnlshed. FIRE SPRINK ENERGY T-24
Z Z ❑ Certific led with the city inspection division. MISC.- RE T D. Y❑ N� Y ❑ N�
A PPlicanl_
LO CIi IT ICA'I'E OI'EXEMPTION FROM WORKERS' PERM CE 00 FLOOD ZONE A.L.U.C.
111 > COMPFNSAIION INSURANCE. PLG.CONTR. LIC.NO. P .AL Y F] N Y O N0
Q. O This seclidn need nut be completed if file pe nn if is for one
D Z hundred dollars(S 100)Or It-)
U O I certify that in fire performance of the work for which this per- TY.OMECHANIC E FEE SUMMARY
IL P mit is issued,I droll not employ any Person in any Ruiner so as to
QU become subject to the Workeri Cornpensafino Lawsof California. BUILDING M3 �.O0
Date Applicznt ALT OR D ECH.
Tai)
N01 ITT '1'0 APPLICANT: IL after rm king this Certificate of Ex- --
? nnpliom,you shomld become subject to the Workers'CmRIN,asallmn A ILIA 5.00 LAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall he decried revoked. AIR H NDLING UNIT IT 3p M.) 4.
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT VE t p00C.F .) .0 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(141TH ON 1 5.0 MICROFILM
the performance of the work for which this peri(is issued ISec.
3097,CN.C.). HEATING UNIT(TO 10 . .U.1 8.00
Lender's Name H EATI NG UNIT IOV ERI M0,000 B.T.U.)9.50 ELECTRIC
Lender'i Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 PLUMBING
information is correct.1 agree to comply with all city and county BOILER-COP/P 13 H.P.or 100,000 B.T.U.) 6.00
ordinances and stale laws relating 4s building construction, end
hereby aulhoVr.
cnlalives of this city to enter uPon IIIc BOILER-COMP Over 100,000BTU)SEE FEE SCH. MECHANICAL
above mentioy for inspection purposes(We) agrndemnify and keep hnmle, he City I MISC.- REFER TO ORD.
uPerlino aies,judgments, costs and Penxes w ch PERMIT ISSUANCE 10.00CONST.TAX
aym y agai rot said City in con quince the
rali MECN.CONT. LIC.NO. MECH.
TOTAL TOTAL SSD
$i 1 of Applicanl/Contreclor Uate
OFFICE COPY