5776 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
AOD 55
_///'�' BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 5776
OWNERS PLAN CHECK VALIDATION
x ME QTY. ELECTRIC PERMIT FEE
C.1t..J PRONE
NT ACT
NUTLETS-SWITCHES-RECEP 5.00/1.00
p
L.C.NO. a L LIGHTING FIXTURES 5.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
PRON ) `j PANELS 5.00 DATE OF APPLICATION
A.C.
SIGNS 61x1 PLAN CHECK FEE P.0 NO.
I
E.G.No. SIGNS TRANS. 3.00 •
ARC".OR ENG. SPECIAL CIRCUIT 5-(� PERMIT VALIDATION
ADDRESS
zlvrrEMP.METER OR POLE INS. 15.00
APPLICANTS IMOTORS SEE FEE SCH.
ADDRESS C
SERVICE CHANGE 10.00
F O o LICIiNS1iD CONTRACTORS DECLARATION
U v I hereby M. that I am licensed under provisions of Chapter 9 _ ,e p�' ISSUANCE DATE
m Z.m (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MEER.
a,m z Professions COJ liccme is in fall fur e- s(�ff L I ❑ ❑ O ❑
z o- Lice Clus _ Lia Numh o
O F w Dale. - Contra Ll r
a x s tt yBU1L^^DING PERMIT
ir ¢w� OWNER-BUILDER DECLARATION '. -�-ro1N FORMALTjhON
o A MISC. REFER TO ORD
E
; A m 1 hereby often( that I am esempl from the Contractor's s License VALUATION SIFT.
� .. o f sec for the following reason.(Sec.7031.5,Busioessand Professions PERMIT ISSUANCE 6.00 j
Code:Any city or county which requiresa permit to construct,alter, y-
QQQ� imp...demolish,(it repair any structure,prior In its issuance,BIW ELEC.CONTR. LIC.NO. ELEC.
IS requires the applicant for such permit to file a signed statement that TOTAL JG PERMIT TO
w m he is licensed pursuant to the provisions of the Contractor's License
Fzi
Law(Chapter 9(commcncing with Section 70004offAvision 3 of the
a Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEEjC
I z O UI TYPE CONSTR.
¢ $ the basis for the alleged exemption.Any violation of Section 7031.5 I
a by any applicant fnrapermi[subjecis the applicant toa civil penalty ALTER-DRAIN IEA.14.00 =2`11S4-!CE
of not more than five hundred dollars(S500)J:
❑ I,as owner or the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure Is not
intended or offered for sale(Sea 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code 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 4.00 SO,FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees.Provided that such improve-
mems are not intended or offered for sale.IL however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
or improvement is Wld within one year of completion,the owner-
--EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the hurden of proving lieu(he did not build or im- RES IND CON PB Cilia,
prove I..purpose.1 sale.). INDUSTRIAL WASTE INTER. 20.00
❑ 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 Pro fcssions Code:The Contractor's License Law Rocs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
cunlmcls for such projects with v wnlractorf s)licensed pursuant to
the Contractor's License L.W. SEWER-SANITARY-STORM EA.200ft/6.00 TRACT NO. PARCEL NO.
O I am exempt under Sec. .B.&P.C.for this WATER HEATER WIVENT 4.00
.,,in
Owner Date WATER SYSTEM 4.00 ACGDATE ACC.FILE NO.
WORK Ii RS'COMPP-NSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm Chat I have a certificate ofconsent to sel Num e, ZONING ENG.SITE NO.
or a certificate ot Workers'Comp•nsatiou Insurance,or a certified
copy the reyj t ,LabaL-� �/ _
1WicY Nose Ipany.(�LS�/(EmK
Q' ❑ Certified co is hereby❑�rmShe FIRE SPRINK ENERGY T-24
Z z ❑ rrertil,ld'J file wi}y,Rsf city inspection division. MISC.- REFER TO ORD. r ❑ N❑ r ❑ N❑
O AppllL'I'^V- L6PS
M w CERT1F-ICATI 01'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU > COMPFNSWION INSURANCE PLG.CONTH. LIC.NO. PLG.
CL O (flus "Do. teed not be completed if the permit is far one TOTAL V❑ N❑ v[:] N❑
Z) z hundred dollars(S 100)or less.)
U O 1 certify mal in the performance of Om work err which(bis per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
H mit is issued,I shall not employ any person in any manner W as to
OW become subject to the Workeri Compensation Laws of California. BUILDING �5G-lZ
Date Applicant ALTER OR ADD TO MECH. 4.00
NOTICE 'I O APPLICANT': If,after making this Certificate of Ex-
? emplion,you should become Subject m the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
C7 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.N7) 3.00
CONSTRUC'T'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this Permit is issued(Sec. MICROFILM
3097,riv.C.l. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.P.50 ELECTRIC
Lender's Address
-
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
. intormation is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorise representatives of this city to neer upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agr. to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
C-IcrtlnI •uinst liabilities,judgmunis, costs and expenses which CONST.TAX
ue
may in a accraga tet said City in consequence the PERMIT ISSUANCE 3.00
gTantingo This mi _ MECH.CONT. ' LIC.NO. MECH.
C �� sQ TOTAL TOTAL ���
Signal eo APplicuntlContnmlpr� Ualc
OFFICE COPY