18379 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY ✓
BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT PERMIT NUMBER
aUILaINr 18 3 7%
f gO t.Dul
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
Ow ER'S PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
°NL Z
O.E crDR's
NOUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
rvo. L' LIGHTING FIXTURES 10.00/1.00
ADDRESS RRAcrors
ADl _� `^ �x PPLIANCES-RESIDENTIAL 4.00
F1'.Ii1j_ I��� !/ _
PNOrvE PANELS 10.00 DATE OF APPLICATION '
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P,0.NO.
OR NIA
ENGINEER
LIC.No, SIGNS TRANS. 3.00
ARCH.ADDRESS Ervc' SPECIAL CIRCUIT 5.00 PERMIT VALIDATIpN
/,)//I- ZIP EMP.METER OR POLE INS. 20.00
1
ADDRESS MOTORS SEE FEE SCH. `
ADDRESS
V -z SERVICE 20.00
o o LICENSED CON'I'RACfORS DECLARATION I '�
a u u I hereby affirm that I am licensed under provisions of Chapter 9 SUANCE DATE
vo <w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H D z Professions C!!dP�I➢��II y�y license is in full lone t ❑ ❑
z o A - License Class�.%„jf[2__Lic.Number ❑
Q w L o Date Contractor
a y s BUILDING PERMIT
arrt w¢ OWNER-BUILDER DECLARATION INFORMATION
rao A " MI REFER TOORD
I hereby affirm that I am exempt from the Contractor's License
3 u w VALUATION $/FT.
Hu o Q Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct Ateq
¢ ¢ < improve,demolish,or repair any slmcture,prior to its issnance,also ELEC.CONTR. LIC.N0. ELEC.
- Q c,ui,,S the applicant for such pc nnit to file a signed slat anent Mal TOTAL PERMIT TO
A w m a, he is licensed pursuant to the provisions o1 the Contractor's License
H z a
Law(Chapter 9(commencingw•ith Section 7000)of Division 3 of the
s 4 o Business and Professions Code)or that be is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ H o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
at
; m by any applicant lin a Permit subjects the applicant lea Civil penalty ALTER-DRAIN -WATER IEA.) 5.00
at not more than se hundred dollars(S500).)!
❑ I,as owner of it,,property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sale compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
inleWed or offered for sale(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 workFIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
lf
himseor thfough his own empinyces,provided that suchnipro
ise-
'�� melts are not intended or offered for sale.e;however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Omar
Prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(See. 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 'ASSESSORS PARC EL NO.
and Professions Code:The Contractors License Low 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 a mmonctods)licensed pursuant to SEWER-SANITARY-STORM EA.2001t/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ tum exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT (QJ 6-00 (XJ
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSA'FION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent t0 self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Conhpensation Insurance,Or a certified
copy thereof[Sec 3g00,Cm IfTrYLab C).
Policy No. Comps hereby turniR✓r(
Q ❑/certified 'c iSsfleturnis ted. FIRE SPRINK ENERGY i<
Z 2 r/ Certif o Y is file th h city asp elaa clivi'ny
p Applicanl_ 5BL9h� -yiE.�Y& misc.- REFER TO ORD. 1 'P' Y � N❑ Y N�
rn
CERTIFICATE OF FXEMPT10N FROM WORKERS' PERMIT ISSUANCE 1 ZI 0 l w FLOOD ZONE A.L.U.O.
LLI > COMPI'NSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y N� Y ❑ N❑
CL O 1'1'his section need not be completed if the permit is for one TOTAL
D Z hundred dollars IS 100)or less.)
U 0 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mil is issued,I shall not employ any person in any,,honer so as to
0U becomcaabjecl to His WOrkers'Conh IFemetic.Laws of California. BUILDING
Dale AppliCam ALTER OR ADD TO MECH. 5.00
} faA
NO]ICE TO APPLICANT: It after making this Certificate of Ex-
F Z elliptical,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK /
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000QF.M,) 4.00
CONST RUCTION L17NDING AGENCY AIR HANDLING UNITIOVER 10MC.F.M.16.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency I'or EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(See. MICROFILM
3097,Civ.C.), HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name- HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
1 certify that I have read this appliculion and Slate that the above VENTILATION FAN (SINGLE) 4.00
bloc nation is correct I agree 10 comply with all city.,,it comityBOILER-COMP13 H.P'or 100,000 B.T.U.) 6.00 PLUMBING
Ji maces and w
slate las relating to building construction, and
re by autorirc representatives of this city to enter upon the BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL
above-m Boned property for inspection purposes.
(We) gree to eve, Inde in and keep hanmlev the City of MISC.- REFER TO ORD.
operon against liabilities,j SI ents, costs and expenses which CONST.TAX
may in ny way accrue ag hst said City in consequence of the PERMIT ISSUANCE 10.00
al in O(1 Sp omit MECH.CONT. LIC.NO. MECH. ,\
�. TOTAL TOTAL /Wl
Sig a of p can o tactor Da e' '
OFFICE COPY