5851 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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BUILDING PROJECTlDENTIFICATION PERMIT NUMBER
APPLICATION & PERMIT
°'"° 5851
ADD 55
/ BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S �7 r - PLAN CHECK VALIDATION
NAN• CITY. ELECTRIC PERMIT FEE PHONE
c NERACTORs UTLETS-SWITCHES-RECEP 5.00/1.00
O LIc.NO. d LIGHTING FIXTURES 5.00/1.00
CONTRACTORS'
ADDREas �� S PPLIANCES-RESIDENTIAL 4.00
ONE O PANELS 5.00 OATS OF APPLICATION
A.CHI ECT - SIGNS 6.00 PLAN CHEC FEE P.C.NO.
ENOR GINEER
' LIC.rvD. SIGNS TRANS. 3.00
moo Ess Enc' SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. .15.00 ^
ADDRESS MOTORS SEE FEE SCH. .
ADRJ
SERVICE CHANGE 10.00 pyt,L
D o o 'LICENSED CONTRACTORS DECLARATION T Nso/ O� (0/4/
a u U I hereby affirm that 1 am licensed muter provisions of Chapter 9 -��{ ISSUANCE DATE
N< tai be a nu.D,G6.g with Section 7000)of Division 3 of ole Business and BLDG. ELECT. PLG. MECH.
r w m Professions Cod am - :cense is in full force and ge '
vq
oz m D License Class Lic.Number O
F w r j Ualcb= Cmttmcmr -••
a se 2 ' BUILDING PERMIT
rt m w< OWNER-BUILDER DECLARATION
INFORMATION
E:
;A u 1'hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
v_0 < law for the following reason. 703L$,Businessand Professions VALUATION S/FT.
r -a g PERMIT ISSUANCE �"Q/y.yyt
f > E Code:Any city or county whichreyairesa Permit to construct, 6�AU 13VlOJ
SE Q O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
a wO u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
m he is licensed pursuant to the provisions of the Coulrndor's License
H z a Law(Chapter 9(commencing with Section 7000)of Division3 oflhe {s. p
4 D Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT iw I�UAW
IF I-o the basis for the alleged exemption.Any violation ol'Section 7031.5 STORIES TYPE CONSTR.
c;m by any applicant for a permit subjects the applicant too civil Penalty ALTER-DRAIN -WATER (EA.) 4.00
of not in..than five hundred dollars(f500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is no[
. intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code:The Contractor's License law does not apply to an owner of
properly who builds or improves thereon,and who sloes such work FIXTURES-PER TRAP 4.00 BD.FT.FLOOR AREA TOTAL ACREAGE
•� himself re through his own employees.Provided that such improve.
mm�Improvenotment
is old or within
ronefor
year
l completer,tile theo nee, GAS-EA.SYSTEM-1INC.4OUTLETS 4.00
or improvement is sold within one your of completion,the owner, GAS EASYSTEM OVER 4(EA) 1.00
builder will.have the lof proving that he did n - . - . BUILDING USE
riot build or int
prove I'or purpose of talale.). RES IND CON Pe OtherINDUSTRIAL WASTE INTER. 20.00 El El D . 1:1
ID as owner of the properly,am exclusively contracting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 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.) 1.00
contracts for such Projects with a contalctons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ •I am exempt under Sec. ,li.&P.C.for this
reason WATER HEATER W/VENT 4.00
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK E RS'COMPENSATION DECLARA IION WATER TREATING EQUIP. 4.00
I hereby affirm that 1 have a certificate of consent to self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereuf(Sce.3800,Lah.C.L
Policy Nn. tpany
O ❑ Ce led rn a fur led FIRE SPRINK ENERGY T-24
Z Z ❑ C fir, ropy i II w Ir7IIc cl j-in' ion division.
O Apphcun =- MISC.- - REFER TO ORD. Y ❑ NM - Yo NC]
~ PERMIT 6.00
LU - CER KATEE EXEMPTION PROM 1VORKCRS' RMIT ISSUANCE vLooD zoNE A.L.U.C.
W � COAIPIiNSAT10N INSURANCE PLG.CONTE. LIC.NO. PLG.
Q Z ('Phis section need not be completed if the permit is for one TOTAL Y N� Y N�
hundred dollars IS 100)or less.)
L) 0 1 certify that in the performance of the work for which,this per. CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued.I shall not employ any person in any mmrner so as In
O U become subject m the Workers Compensation Laws of California.
ED Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING Qa
} m NOl'ICE'1'0 APPLICANT: If,after making this Certificate of Es-
? emption,you should become subject to the Workers Compensation APPLIANCE 4.00 PLAN'CHECK
provisions of the 1-char Code, you must forthwith comply with -FEE,
V such Provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10ACC.F.M.) 3.00
CONST'RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=11F.M-) 5.00 SEISMIC FEE S�
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the petiormance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lenders Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Limiters Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct.I agree to comply with all city and county PLUMBING
ordinances and slate laws relating to building construction, and BOILER-CONP(3H.P.or100,000B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000BTU)SEE FEE SCH, MECHANICAL
abovrmentioned properly for inspection Purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.'- REFER TO ORD.
upon hest liabilities . d mC s,costs and expenses which -PERMIT ISSUANCE 3.00 CONST.TAX
m any ace against ily in conscyuence of the
grantin his I. ECH.CONT. LIC.NO. MECH.
A2 >_J TOTAL TOTAL \5r,/slur Date
-J'
OFFICECOPY