13420 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -,USE BALL POINT PEN ONLY
t' BUI LDI NG PRO46C I DENTI FICA710N PERMIT NUMBER
G awLOING APPLICATION & PERMIT
DING-ELECTRICAL-PLUMBING-MECHANICAL 13420
•� N' '�(_J Vr v-41 PHO II✓� PLAN CHECK VALIDATION
QTY: ELECTRIC PERMIT FEE`
N R c s UTLETS-SWITCHES-RECEP 10.00/1.00
uc.N 4 LIGHTING FIXTURES10.00/1.00
/9q6�$/ro R' APPLIANCES-RESIDENTIAL 4.00
1 L/ 6 PANELS - 10.00 DATE OF APPLICATION
opcRlTEcr
PANELS (OVER 200 AMP) '20.00 PLAN CHECK FEE P.C.NO.
ENGINEER '
LIC.NO. SIGNS TRANS. 3.00
RREes ENG. - SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADC
ZIP EMP.METER OR POLE INS. 20.00
AP A" .s
A MOTORS SEE FEE SCH.
u 4
' SERVICE CHANGE 20.00 � .
o o LICENSED CONTRACTORS DECLARATION ,///T^/ I
a u w 1 hereby affirm that 1 am licensed under provisions of Chapter 9 955Ua NCEMATE I T "
fcommemm�g wdl ection 0001 of Division 3 of the Business a
wi Professions Cor) c nsa is in full for BLDG. ELECT. PLG MECH.
Z, o l2 - License ass Lic.Number "
s
LY oW Date Contractor ❑tlA/ r 1 Bt �,n
M a w < OWNER-R-BUILDER DECLARA 10 BUILDING PERMIT
o A INFORMATION,
K 3 LL I- 1 hereby affirm'-that I an exempt from the Contractor's License. 'MISC.- REFER TO ORD
r LL Oat Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE VALUATION $/FT.
Code:Any city or county which requires a permit m construct,alter, 10.00
a ¢ improve,demolish,Or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
o wm LL requires.fhe applicant for such permit to file a signed statement that TOTAL MIT Jfa
he is licensed pursuant to the provisions of the Contractor's License �"•'
� >
Law(Chapter 9(commencing with Section 7000)of Division 3 of the - r
E EE z a Business and Professions Code)or that he is exempt therefrom and OTY. .PLUMBING•PERMIT FEE
¢ H the basis for the alleged exemption.Any violation of Section 7031.5 ° '" ` STORIES- I ;YPE CONSTR.
a3 � by anyapplicam for a permit subjects the applicant to a civil penalty .'1.
of not more than five hundred dollars(5500L) ALTER-DRAIN&VENT-WATER (EA.) 5.00 -
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the,structure Is not OCC.
, GROUP RES.UNITS
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 t
Code:The Contractor's License Law does not apply to an owner of
Properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTALACREAGE.
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). - INDUSTRIAL WASTE INTER. 30.00 ,AES IND CON PB oma,
❑ Las owner of the property,am exclusively.contracting with .E] El
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 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 contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑, I am exempt under Sec.-,BAPC.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
wII �t*ENSATION DECLARATION WATER TREATING EQUIP. ' 5.00
l reby affirm that I have a certificate of consent t0 self-insure,
or a certificate of Workers'Campion n Insu a a c I fi ZONING ENG.SITE NO.
copy Thereof ISec.3800,Lab.C. . _
Policy No. Company
O ❑ Cetll lied cnt op ',herb u shd FIRESPRINK ENERGYT-24
_Z Z ❑ Certified py is -li lh e city inspection division. MISC.- REFER TO ORD. YE] N� YQ N[]
APPlicCer
~ �+ PERMIT ISSUANCE 10.00
- CF:RTIFIC TEO EX MPTI ON FROM WORKERS' FLOOD ZONE 'A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO, • PLG. -
O_ O fThis section need not be completed if the permit is for one TOTAL Y❑ IN O Y N
Z hundred dollars($100)or less.)
U O 1 certify that in the performance of the work for which this per- 'OTY. 'MECHANICAL PERMIT FEE FEE SUMMARY"
LL 1- mit is issued,I shall not employ any person in any manner so as to u
O W become subject to the Workers'Compensation Laws of California.
Date Applicant ' ALTER OR ADD TO MECH. 5,00 BUILDING
>_ tail NOTICE TO APPLICANT. If,after making this Certificate of Ex-
Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO(10,000C,F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLINGUNIT(OVER IO,000C}.F,M.),6.00 SEISMIC FEE
I hereby affirm that there is.a construction lending agency for EXHAUST HOOD(W ITI-1 DUCT) 1;;'.%I 5.0
the performance of the work for which this permit is issued(Sec. -MICROFILM
3097,r's Na). ' H EATING 00 (W
B.T.U.) 8.00
Lender's Name - '
Lender's Address H EATIN G U N ITER I OQ,OQQ B':T.U7) .50 ELECTRIC
1 certify that 1 have read this application and state that the above VE NTI LAT
ION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county PLUMBING eye
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00 /
hereby authorize repent fi rives of this city es enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
heave-mentioned prepres representatives
of this
purposes.
(wAavd mnify end keep harmless the Clty of MISC.- REFER TO ORD.
Cuperjudgments, costs and expenses which PERMIT ISSUANCE - 1Q,QQ NST.TAX
' a mat said City in consequence of thegran LIC.NO. MECH.
TOTAL ^ ^ignatntractor Date 2 (�/ / y.✓, TOTAL
OFFICE COPY' VVV 'C