16996 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
13U LDI NG PROJECT IDENTIFICATION " -PERMIT NUMBER
BUILDING APPLICATION & PERMIT 16996
ADDRESS
/o 3`7 /Y1
R,q 157 BUILDING -ELECTRICAL-PLUMBING-MECHANICAL + U J U
OwNER'syP C 7-p - PLAN CHECK VALOAT16N ,
NAME QTYELECTRIC PERMIT FEE
,J : Li✓a aJ NE 3 . ea
ONTRA TOR'3"
NAME - OUTLETS-SWITCHES-RECEP 10.00/1,00
C'L Df /4 L uC ND O7S' LIGHTING FIXTURES 10.00/1,00 �
CONT ACTOR'S C/f0�/ APPLIANCES-RESIDENTIAL 4.00
- ADDRESS //.. rr /)
74 (( 1441 ,ONE 410-?13 PANELS 10.00 DATE OF APPLICATION 1
ARCHITECT ✓ CFLTWO 0 AMP) 20.00 PLAN CHECK FEE P.C.-NO.
IOR PANELS (OVER 20
A
ENGINEER
' uc.NO, SIGNS TRANS. 3.00
ARCH.ORENG. SPECIAL CIRCUIT 5.00 PERMIT
' ADaREss I
_ ZIP TEMP.METER OR POLE INS. 20.00
ASMOTORS SEE FEE SCH. q �qSQ'
ADDREDOREsS F7 l nIQ
O 6S PRi 19 G CL ' ER i adc SER HAN E 0
Foo LICENSED CONTRACTORS DECCA ATION _ `
M v w I hereby affirm that I am licensed under provisions of Chapter 9 1 U NCE DATE
(commencing with Section 7 .f Division 3 of the Business and BLDQ- 'ELECT. PLG. MECH.
0 . i Professions Code,and license nse is is full force and effect. COMP. W
z
0. - License Class-Lin.Number
Q m r
Date - Contractor
BUILDING PERMIT
¢ ce a OWNER BUILDER DECLARATION
o iL u .- - INFORMATION
E.
; LL w ,I hereby al tion that 1 am exempt from the Contractor's License MISC. REFER TO ORD
r u o a Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT. r
Code:Any city or county which requiresa permit to construct,alter, _
2 K Q p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO: ELEC. p O f
n w0, requires the applicant for such permit to file a signed statement that TOTAL 1 U l� PER�yMIT TO
m ac he is licensed pursuant 10 the provisions of the Contractor's License 5 F/.JNU ,
Hz > Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe L
i,o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ rc, the basis for the alleged exception.Any violation of Section 703 C5 STORIES TVP CONSTR.
Ate - by any applicant for a pehnitsubjects the applicant toacivilpenalty ALTER-DRAIN -WATER IEA.)'5.00 .
of not more than five hundred dollars(55000.):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4,00 OCC.GROUP RES.UNITS 1
their sole compensation,will do the work,and the structure Is not r
intended or offered forsale (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 does such work FIXTURES=PER TRAP 5.00j[1
Flppq/[I)EA TOTAEACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-11 6.00 OO��
merits are not intendedor offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner, GAS EASYSTEM-OVER 4'(EA ) 200
builder will have lire burden of proving that he did not build or im- - . . . BUILDING USE
RES NO CON PB Othe,
prgve for purpose of sulaJ INDUSTRIAL WASTE INTER. 30,00 ❑ ❑ ❑ ❑
.DV4 1,as owner of the propetly,am exclusively contracting with
licen ed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- I INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00 .•357 ^, 0 '
contracts for such projects whhucontractors) icensed pursuant to SEWER-SANITARY-STORMEA.200ft/70.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ I ant exempt under Sec. ,BAP,C.for this WATER HEATER W/VENT 6.00 -
reBSOn
Owns Data WATER SYSTEM- 5.00 ACC.DATE ACC.FILE NO.
- KE M111" TION ,ARAT]ON WATER TREATING EQUIP. 5.00 1
1 hereby uffl e a certificate of consent to self-insure,
or a calliflcate o W.rkcrs'Compensation Insurance,or a cerlil red ZONING ENG.SITE N0,
copy thereof(See.3800,L.h.C.). -
Policy No. COC Pdny
0 ❑- Certified copy is hereby furnished.
FIRE SPRINK ENERGY T-24
Z ❑ Certified copy,is,filed with the city inspection tliviei
0 oa
p Applicant - MISC.- REFER TO ORD. v ❑ N❑ v ❑ No
CC rPERMIT ISSUANCE 10.00
� - CCERTIFICATEOI'EXEMPTION FROM WORKERS' PERMIT ZONE A.L.U.C.
UJ COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG,
(L 0 (This section need not be completed if the permit is for one TOTAL V[:] N❑ V [:] N❑
_ � z hundred dollars IS 1001,.,less.) -
U O 1 certify that In the performance of the work for which this per. OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued, I shall not employ any person in any manner so as to
5.00
ALTER OR ADD TO MECH.
U' become subject to the'Workers'Compensation Laws of California.
LU Date Applicant _ BUILDING
.'} ra' NOTICE TO APPLICANT: If,after making this Cerlllicste of Ex- 10
' 1
F Z emption,you should become subject tin the WorkersCompensation 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=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) ,.. 5.00
31097 performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRICQ Sa
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4,00
formation is correct. I agree to comply with all city and countyPLUMBING
ordinances'.and stale laws relating 10 huilding construction, and BOILER-COMP(3H.P.or100,0008.T.U.1 6.00
herehy authorize representatives of this city to enter upon the BOI LER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL 0
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep armless the City of MISC.- REFER TO ORD. b
u ertino against liabilities,judgments, SPIP SP. and expenses which CONST.TAX 3a71.i79
° may a any way aCCTQ •.agailld m consequence of the PERMIT ISSUANCE 10.00
ranting ((Itis petntil. MECH.CONT. - LIC.NO. MECH.
TOTA(}�
TOTALe 3( 4"7Sig tore pP)' ant/C' r Date 1 g L
--- OFFICE COPY