10702 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 10702
ADDRESS
UILDIN
10727 Rand Lane BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S -PLAN VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
Mr. & Mrs. Terry Grj &iLn
CONT ACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
NAMECity Lic. 8050
LIC.ND. 146361 tAGHTING FIXTURES 10.00/1.00
ADDRESS
CONTRACTORS
ORs ppL NCES-RESIDENTIAL 4
A
PHONE 293-471 PANELS 0.00 DATE OF APPLICATION
on
ARCHITECTPLAN
OO AMP) 20.00 PLAN CHECK FEE .C.NO.
ENGINEER
LIC.NO, SIGNS TRANS. 3.00
AARCH.OR DDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDA ON
ZIP EMP.METER OR P%X I ft, 20.00
Ars
ADDRESS MOTORS S FEE SCH.
DRESS E55 r
SERVICE CHAP4dE 20.00
w
02 LICENSED CON'PRACTORS DECLARATION
a
to u I hereby affirm that I am licensed under provisions of Chapter 9 IS CE DATE
'o (commencing with Section 7000)of Division 3 of the Business and BLDG. 'L°C PLG.
a i 0143 &y C 3`46i'361 & \
Professions C d ends m full Ir f'• ❑ ❑
o i w o License Ch ss tiY Number'
Date Contractor_��71(i.r)_
¢x f BU DING PERMI
¢ le w OWNER-BUILDER DECLARATION IN ORMATION
w ; v y I hereby affirm that I am exempt from the Contractur's Licet MISC - REFER TO ORD
F e_ o g Law for the following reason.(Sec.7031.5,Businessand Professions PER IT ISSUPIN CE 10.00 O VALUA ION $/FT.
Cade:Any city or county which requires a permit to construct,alter,
2 to Q 0 Improve,demolish,or repair any structure,prior to Its ISivance,also ELEC.CON R. LIC.NO. ELEC.
G LL requires the applicant for suet)permit to file a signed statement that TOT PE MI T
,v w mhe is licensed pursuant to the provisions of the Contractor's License
Fi >
Law(Chapter 9(commencing with Section 7000)of Division 3 of the !sz
a Business and Professions Code)or that he is exempt therefrom and QT:Y. PLUMBING PERMIT. "FEE
¢ $ the basis for the alleged exemption.Any violation of Section 7031.5 n k,1eToJits TYPE CONSTR.
i ; _ by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollan($500)):
❑ I,as owner of Bte property,ar my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sale compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who data such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale.If,however.the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner-
builder
wner GAS EASYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build Or ire- - . BUILDING USE
prove for purpose of sale.). INDUSTRIALWASTE INTER. 30.00 E IND CON Pa Omar
❑ 1,as owner at the property,am exclusively contracting with ❑ ❑ ❑ ❑
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 contractor(s)licensed pursuant to SEWER-SA V-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sea ,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACO.FILE NO,
WORK ERS'COMPFNSAT10N DECLARADON WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to suit-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereCJSt a Co
Policy No. Ipany q
O ❑ Certil dcopyi mrcbyf r�P4ng IkIPM FIRE SHRINK ENERGY T 24
Z 2 ❑ Cer it d cop is de ' c vision.
PO Applicant' 4 0, MISC- REFER TO ORD. Y❑ N❑ Y ❑ N❑
= T CE CATE OF h(EMPT N FROM WORKERS' PERMIT ISSUANCE 10.00 FLDDD ZONE A1.U.C.
W COMPENSATION NSURANCE PLG.CONTR. LIC.NO. PLG.
TOTAL Y❑ NE] Y ❑ NE]
CL 0 (This section need not be co pleted it the permit is for one
hundred dollars(S 100)or I.,.)
U O I certify that in the performance of the work for which this per- OTY..' MECHANICAL PERMIT =FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
tL Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} US NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z empDon,you should become subject to the Workens Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.FM.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT IT
O 100,000 B.T.U.) 6.00
Lender's
NameHEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Addo,ss
I Certify that l have read thisapplication andoate tlmt theabove VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
01
dirm ccs and state laws (elating to building construction, and BOILER-COMP(3 H.R cr100,000B.T.U.) 6.00
June
authorize representatives of this city to enter upon lha BOI LER-COMP(Over 100.000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cup' ainst liabilities,judgments, casts and expenses which PERMIT ISSUANCE 10.00 Q NST.TAX
may m en way accrue against said City in consequence of the
grunt g of 11 is permit MECH.CONT. LIC.NO. MECH, ,
TOTAL[, TOTAL
'gnat is o c
UCt r D '.-8.7_ ' )��. //1
OFFICE COPY C?