C8232APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
• 6U!.LCJ NG PROJECT I DENTI FICATIONPERMIT
L
APPLICATION & PERMIT
BUILDING -ELECTRICAL- PLUMBING -MECHANICAL
_R
NUMBER
8232
BUILDING
ADDNES
_HvnE.
AME
C PHONE419A 6194S
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION -
NAME ci0 s
NAME
UTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
LIC. NO. 61
A WOOD
GATE OF APPLICATION
CONTHaIT Rs 6000 16'
ADDRESS 1�
• vR0 •
PPLIANCES- RESIDENTIAL 4.00
PANELS10.00
ARCHITECT
OR
ENGINEER
LIC. No.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH. OR E
?
SPECIALCIRCUIT $.QQ
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
\
ADDRESSTs
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
/
EO/`//��
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
1 hereby affirm that 1 am licensed under provision of Chapter 9
(commencing with Section 7000) of D ision 3 o h u5iness and
Professions C c, y liccnsc n in fu
I.icen Cl u Lie. Num
ISSUANCE DATE
BLDG.
❑
ELECT PLG. MECH.
El, ❑
Dote. Contra'to
BU I L DINO R T
I
OWNER -BUILDER DECL ATION
I hereby affirm that 1 am exempt from the Contra tor's \icense
Law for the following reason. (Sec. 7031.5. Businessa dPro •scions
Code: Anycity orcounty which reyuiresa permit loco strut alter, a
improve, demolish, or repair any structure, prior to its is e, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
A ION .
MISC. - REFER TO ORD
_U TION
/
h� FT.
PERMIT ISSUANCE 10.00
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL
PERMIT TO
OTY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
STORIEST
PE CONSTR.
the basis for the alleged exon. piton. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of nut more than five hundred dollars ($500).):
ALTER -DRAIN & VENT -WATER (EA.) 5.00
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the stn¢ture is not
intended or offered for sale (Sec. 7044. Business and Professions
BACK F LOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AR EA, 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 5.00
so. FT. FLOOR AREA
TOTAL ACREAGE
himself or through his own employees, provided that such improve-
mentsarenotintendedorofferedforsale. If, however, the building
GAS - EA. SYSTEM -11 NC. 4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that h e did not build or im-
prove for purpose of sale.).
I, as owner of the property, am exclusively contracting with
. ..
GAS - EASYSTEM -OVER 4 (EA.) 200
BUILDING
RES
5 IND
USE
PB OIheI
El 11
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
LAWN SPRINKLERS -OVER 5 (EA.) 1.00
ASSESSOR PARCEL NO.
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon. and who
contracts for such projects with a contractor(s) licensed pursuant to
the Contractor's License Law.
SEWER -SAN ITARV-STORM EA. 200ft/10.00
TRACT NO,
PARCEL NO.
WATER HEATER W/VENT 6.00
❑ l am exempt under Sec. ,B.&P.C. fnr this
reason
Owner Date
5.00
WATER SYSTEM
ACC. DATE
ACC. FILE NO.
WORKERs'CO MPENSATI N DECLARATION
WATER TREATING EQUIP. 5.00
I her y affirm Thal I have I cYrtifI a of consent to self -insure.
ce I kale of Workers' nn e s n ra c •, edified
Orsic
copy Ili
ZONING
ENG. SITE NO.
Policy
�ed L
FIRE SPRINK
ENERGY T 24
❑ C it yis rrcby-Hilo o a
9/Cer' co 's 1111 e c division.
App teen.
Y N�
Y [:] N[]
MISC.- REFER TO ORD.
CER It COF F.XEM TI 'FRO WORKERS'
PERMIT ISSUANCE 10.00
FLOODZONE
A.L.U.C.
PLG. CONTR. LIC. NO.
PLG.
TOTAL
COMPENSAI'10' NSURAN E
(This section need not be corn fired if me Penn it is I'or one
YE] N�
Y[:] N[D
CITY MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars(S 100) or less)
1 certify that in the performance o he wo for which this per-
mit is issued, 1 shall not employ any per any manner so as to
become subject to the Workers' Compensation Laws III California.
Date Appitemat
N'O'TICE TO APPLICANT: If, after making this Certificate IT ex-
emption, you should become subject to the Workers Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
BUILDING
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10=C.F.NL) 4.00
AIR HANDLING UNIT (OVER 10=C. EM.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, Co,.C.),
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATI NG UNIT(OV E R 100,000 B.T.U.) 9.50
ELECTRIC
Lender'S Name
Lender's Address
I certify that 1 have rca misapplication and state that the above
'nl'ormation IScorrect I a •e to comply with ell city and county
rdinances sad state laws sting to building construction, and
VENTILATION FAN (SINGLE) 4.00
PLUMBING
BOILER-C01VlP(3H.P.or100,000B.T.U.) 6.00
BOILER -COMP Over 100.000 BTU) SEE FEE SCH.
MECHANICAL
ereby authorize represent I es of this city to enter upon the
hove -mentioned prop t fo pec6on purposes.
MISC.REFER TO ORD.
TAX
(We) agre!to save, i em ' and keep harmless the City of
pert agst liabil ii , ju tents, costs and expenses which
y i a y Seem la Bins! id City in consequence of tgr.
PERMIT ISSUANCE 10.00CONST.
MECH. CONT. LIC. NO.
MECH,
TOTAL
TOTAL
I/
. /
[it u per i1. 1•/$
af Applic t/Contractor Uatc
mre o
OFFICE COPY