11308 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMITESS
11308
ADDIke)
1 f`s 1 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'9 . ' PLAN CHECK VALIDATION
NAME DTYt -':.:': if"r ELECTRIC PERMIT FEE
�,� (C`Tp} PHONE
NANTRACTOR s UTLETS-SWITCHES-RECEP 10.00/1.00
NAME gg
1I, jR-A LIC.No. ��3l6 LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S
ADDRESS PPLIANCES-RESIDENTIAL 4.00
n
LrjCfr` 1 �. PHONE '--6I �I PANELS 10.00 DATE OF APPLICATION
ARCHITECT - PANELS(OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
- Sec.No. SIGNS TRANS. 3.00
ARCH.OR ENG. - SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
Woo LICENSED CONTRACTORS DECLARATION /
¢u v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
a: z w (commencing with Section 7000)of Division 3 of the Business and
BLDG. ELECT. PLG. MECH.
G y z Professions Code and my license is in full for and tett ref
o Z m W License Cla Lia Number ❑ ❑ ❑ I`S,J
Date n
Contraor
¢Y f 11
t IF
- BUILDING PERMIT
Q ¢ w u OWNER-BUILDER DECLARATION INFORMATION
wD A MISC.- REFER TO ORD
;ar I hereby affirm that I am exempt from the Contractor's License
Od Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION
u Code:Any city or county which requires a permit to construct,alter,
¢ ¢0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
a w m¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
he is licensed pursuant to the pnrvisions of the Contractor's License I /°1( //
H t
Law(Chapter 9(commeneingwilh Section 7000)of Division 3 oflhe
¢ �'�`
i c Business and Professions Code)or that he is exempt therefrom and DTV.' PLUMBING PERMIT FEE
¢F 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 IEA.) 5.00
of not more than five hundred dollars(S500).1:
❑ 1,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 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 work F IXTUR ES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenot intended oroffered for sale.If,however,the building GAS-EA.SYSTEM-l1NC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner GAS-EA.SYSTEM-OVER 4 (EA.) 2,00 BUILDING USE
-'
r builder will have the burden of proving that he did not build or im-
provefor purpose ofsaie.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ 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: 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1 1.00
contracts for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec, ,B.&BC.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of COnrent to self-insure,
or a Certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.)
Policy No. Company
0 ❑ Certified cop hereby furnis FIRESPRINK ENERGY T-24
Z 2 � Certifi 'op is filed wit Ie city inspec bn i 's
O 'APPdcros MISC.- REFER TO ORD. v❑ N❑ v ❑ N❑
~ vs PERMIT ISSUANCE 10.00 FLOOOZONE A.L.U.C.
2 CERTIFICATE E SATI ION FROM WORKERS'
W �_ COMPENSATION INSURANCE. PLG.CONTR, LIC.N0. PLG.
Q. (This Section need not be completed if the permit is far one TOTAL Y❑ N❑ Y ❑ N❑
0 2 hundred dollars IS 100)or less.)
0 O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL - mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
0 Wa Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z empium,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 orthis permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,0006F.M.) 4.
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT IOVER10p00CiF-M-)V.60 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH b UCT) 5.
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000,8 T r,GTT MICROFILM
3097,CN.CJ, x
Lender's Name
Lender's AddH EATI NG UN It(OVER 100B.T.U.)9.50 ELECTRIC
ress
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER•COMP(3 H.P.or 100,000B.T.U.) 6.00
/ hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)§EE FEE SCH. 'MECHANICAL
}-, above-mentioned property for inspection purposes.
(We) agree to save, indemnify and ke harmless the City of MISC.- REFER TO ORD.
Cuper o against liabilities,judgments, c is and expenses whichCONST.TAX
may y way ace a against said Cif consequence of the PERMIT ISSUANCE 10.00 O
granti o thispermit. MECH.CONT. LIC.NO. MECH.
ilkTOTAL TOTAL
¢ant o me or Date /
OFFICE COPY