12754 Ap ICANT'TO FILL IN INFORMATION WITHIN RED LINES - USE'BALL POINT PEN ONLY
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UILDING PROJECT IDENTIFICATION PERMIT NUMBER
NGAPPLICATION & PERMIT ��� Ass (�BUILDING-ELECTRICAL-PLUMBING-MECHANICAL'a PLAN CHECK VALIDATION
OTY. ELECTRIC PERMIT FEE
�JAh\ ti1 R+DNE� J -J�e
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CONTRACTORS OUTLETS-SWITCHES-RECEP 10,00/1.00 n
N,fP�ME .1
'�._ Q uc.rv0. `I472 LIGHTING FIXTURES 10.00/1.00 I,I
coNTRACTORs APPLIANCES-RESIDENTIAL 4.00
ADDRESS T
��� �� k•1 S70N E,171qq
71-0-/a.w)- PANELS - 10.00 DAT O LIGATION
- ARcnfTscr - PANELS (OVER 200 AMP) 20.00 PLAN CHECK ' 1 P.C.N0.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00 ! 1
ARCH,ORENG. , SPECIAL CIRCUIT S.00 IPERMTVA LIDATION'
ADDRESS r /�� ) 1
• .• zap EMP.METER OR POLE INS. 20.00 t •}PAIIQ..
APPLICANTS MOTORS ^ SEE FEE SCH.
ADDRESS• p
,ANJAN,
p/,) q
SERVICE CHANGE 20.00 tiJ li l'.I 1987
0 0 o LICENSED CONTRACTORS DECLARATION ` Q��s�wt/�,�
a u u I hereby affirm that I am licensed under provisions of Chapter 9 C•9 w15N E
< <N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MW
Hoz Professions Code ardo license is in full fore aaCff�}� ::::::::] ❑ ❑ ❑
z o'y- License Class C-'iiaeLL�J I C Number •- �Cf't"'
9 z H Date_I '� ' Contractor
a YBUILDING PERMIT
¢ ¢ w OWNER-BUILDER DECLARATIONINFORMATION
ii o A •• MISC.- REFER TO,ORD
"I hereby affr. that I am exempt from the Contractor's License - VALUATION S/FT.
F .. o J 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,alter,
ar x Q 2 improve,demolish,or repair any structure,prior to Its Issuance,also ELEC.CONTR. LIC.NO. ELEC.
-o¢ requires the applicant for such permit to file a signed statement that TOTALq
' w es P. he is licensed pursuant to the provisions of the Contractor's License
F z Q
Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe
i 0 Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant toacivil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(5500).):,
❑ I,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,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of -
propertywhobuildsorimproves thereon,and who docs such work '. FIXTURES-PER TRAP 5.00 SG.FT.PLOOR AREA TOTALACREAGE
hinnsell'or through his own employees,provided that such improve- GAS-EA.SYSTEM-1 1NC.4 OUTLETS 6.00 .
f mal
es are not intended or offered for sale.U;however,the building
or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING SE
builder will have the burden of proving that he did not build or int- HES IND PS Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑
❑ 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. 6.00 gSSESSORS ARCEL 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.) 1.00
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.
❑ I um exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT .,6.00
reason
owner Data WATER SYSTEM 15.00 ace.DATE ACC.FILE No.
WORKERS'COMPF.NSATION DECLARATION WATER TREATING EQUIP. 5.00 ,
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO,
or a certificate of Workers'Compensation Insurance,or a certified
copy there LSec.3800 Lab C.1.
Policy No. r ImpanY �tiJTY %/l/l1-f
O 0 Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Zetli(ie co p_y is fi�-
e
I the city inspection-division. ❑ No Y C] No
O At'wanl t- � 1- Ai L MISC.- REFER TO ORD. Y
FCOMPIiLU y CERTIFICPERMIT,ISSUANCE 10.00 FLOOD ZONE A.L.U.C.'
COMPE EXEMPTION FROM WORKERS'
LU �_ NSAT'ION INSURANCE PLG.CONTR. UC,rv0. 'PLG.
f1 (This section need not he completed if the permit is for one TOTAL V❑ N❑ V ❑ N❑
Z hundred dollars 1$100)or less.) '
U O I certify that in lire performance of tire work for which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H ntit is issued,I shall not employ any person in any manner so as to
,.mow become subject to the Workers''Compensation Laws of California. BUILDING.
Datc - Applicant ALTER OR ADD TO MECH. 5.00
} y NOTICE TO APPLICANT: If,after making this Certificate is Cx-
f- Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 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 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY- AIR HANDLING UNIT(OVER 10p00C.FM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD-(WITH DUCT) 5.00
lire performance of,the work for which this permit is issued(Sec a MICROFILM
3097,Cie C.).• I HEATING UNIT(TO 100,000 B.T.U.) 8.00 �'
Lender's Name -
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.0.50 ELECTRIC
I certify that 1 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 BAILER-ODMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and slate laws relating to building construction, and
(.� hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTUI SEE FEE SCH. MECHANICAL
abuve.mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cup lino against liabilities judgments, costs and expenses whichpERM1T ISSUANCE 10.00 /dA` CONST.TAX
may n any way"ecru a� rest said.City in consequence of lire
an ng of this permit. MECH.CONT. LIC.NO. MECH.
- '� TOTn CSD TAL
Signature of Applicant/Contra Date u-• (V /
OFFICE.COPY a 9