8978 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT'PEN ONLY
( - 7+ PERMITNUMS ER
BUILDING BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT.
r BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 8978
OWNER'S _ PLAN CHECK VALIDATION
F / TY. ELECTRIC PERMIT FEE' «
P N
/ NAMER"croRS UTLETS-SWITCHES-RECEP 10.00/1.00 ..
I.C.NO. LIGHTING FIXTURES 10.00/1.00
ADDRESS TORS PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS(OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. ISIGNS TRANS. 3.00
ZRCH OR ADDRESS ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS, 20.00
AESS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
o w o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a °u I hereby affirm that I am licensed under provisions of Chapter 9
ISSUANCE GATE
a
(commencing with Section 7000)0(Division 3 of the Business and BLDG. ELECT. L MECH.
1 F i Professions Code,and my license is in full force and effect. ❑ ❑ ❑
p i H O License Class Lie.Number
F w j Date Contractor
o w u OWNER.BUILDER DECLARATION BUILDING ER IT
uAxi ; w H I hereby ul'firm that I um exempt from the Contractor's License MISC.- REFER TO'ORD INFOR ATION
Hu0 J Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE10.00 VALUATION $/FT.
Code:Any city or county which requires a permit to construct,alter, ,
,Ce ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO.. EIEC.
u
requires the applicant for such pemsit to file a signed statement that TOTAL PERMIT TO
o. w m,A he is licensed pursuant to the provisions of the Contractor's License
H z s- Law(Chapter 9(commencing with Section 7000)ofDlvision 3 ofthe
2 c Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
M H the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
e3 _ by anaplicant for a of not mom than five huermit ndred dooects the llars($500)santloacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 1,as..net of the property,or my'cimployecs 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,AR EA,COND. 5.00
Code:The Contractors License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.90 SD.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.Provided that such improve
or nts improveme.notnt is sold or within
onefor year
fcohowever,tion the theo owner. GAS-EA.SYSTEM-1 INCA OUTLETS 8.00
+ or improvement is sold within one year of completion,the owner
buil4r will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING uSE
P
I.a,onposeofsele.). INDUSTRIAL WASTE INTER. 30.00 IND CDN PB 13
I.
as owner IS the property,ons exclusively. 7044,Bu with �.
tr.� r�aavrmr
dcontractors: constructthe project(Sec. 7044,Business LAW N SPRINKLE 5V.B. 6.00 ASSESSORS PARCEL NO.
afessions Code:The Contractor's License Law does not apply
t of properly who builds or improves thereon.and who LAWN SPO INKLE OVER 5(EA.) 1.00
cels forsuch projects with a contractors)licensed pursuant m SEWER-SANIT S SHvI A;200ft/10.00R
tradorS LiCenu Law. TRACT NO. PARCEL NO.
xempt under cc. ,BAP.C.for this WATER HEA / NT 6.00
a WATER SYSTE ,
e m 5.00 ACC.DATE ACC.FILE NO.
- WORKERS'COMPENSATION DECLARATION WATER TREAT EQUIP. 5.00
by affirm that I have a certificate of consent 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 ropy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is riled with the city inspection division. MI C.- REFER TO ORD.
p O Applicant Y [D N� Y [] N�
CCN CERTIFICATE OIt EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.D.C.
LU COMPF.NSATION INSURANCE PLG.CDNT IC.NV pLG.
CL Cl (This section need not be completed if the permit is for one TOT Y[] N� Y ❑ IN
:) Z hundred dollars($100)or less.)
U O I certify that in the performance of the work for which this per. CITY. MECHANICAL PERMIT FEE FEE SUMMARY
,. LL f- mit is issued,I shall not employ any person in any manner so as to
O w become subject to the Workers'Compensation Laws of California.
y Date ApplicantBUILDING
>_ N NOTICE: TO APPLICANT', If,alter making this Certificate of Ex- ALTER OR ADD TO MECH. 5,00
Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.130 PLAN CHECK
provisions of the Labor Code, you must forthwith comply withFEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 1000C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which [his permit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct.1 agree to comply with all city and county PLUMBING
ordinances and slate laws relating l0 building construclion, and BOILER-COMP(3 H.P.Of 100,000 B.T.U.) .6.00
hereby authorize representatives ins of this city es toter upon the BOILER-COMP(Over 100,000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned property for inspection this
puity to.
fWe) agree to save, indemnify m gqkeep harmless the City of MISC. REFER TO ORD.
Caper' amm liabilities,judgn K, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may at way accor agaimt Id City in consequence of the
g II g of this PC it MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL --
S urea(r pylic Contractor Data
OFFICE COPY