12875 A*LICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
SOILDING APPLICATION & PERMIT i
ADDRESS 10727 Randy Lane BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 12875
OWNER'S PLAN CHECK VALIDATION 1
�ME
r. & Mrs. Terry Griffin 996-114 OTY. ELECTRIC PERMIT FEE
CONTRACTOR'S City Lic. SOSO UTLETS-SWITCHES-RECEP 10.00/1.00
NAMEA:A.A, 'Furnace CO, LID,No 346361 LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
Tfjljy Storie Ave, PHONE293-4717 PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
E NGWEER
L SIGNS TRANS. 3.00
ADDRESS OR EN SPECIAL CIRCUIT S,QQ PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 PAID -
APPUCANr MOTORS SEE FEE SCH.
ADDRESS R AMO
SERVICE CHANGE 20,00 lift /,f - 1987
w o 0 LICI'-NSED CONTRACTORS DECLARATION Ls'/„
v v 1 hereby affirm that I am licensed under provisions of Chapter 9 V I
y<w (commencing with�,S,Iefction 7000)of Division 3 of the Business fend BLDG. ELECT. PLG. E
F y i Professions Cale;45 m&Iic�insejypl full for P,' [{ L �.
i O y- License Class LfkCY umber 34i5'36`�. & El
o o Date_2=2.]-$] ConlractOr-- T7-1-45
a Y s BUILDING PERMIT
OWNER-BUILDER DECLARATION INFORMATION
w ;n H I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION $/FT.
u. D¢ Law for the following mason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
fN>ECode:Any city or county which requires a permit to crnstolet,alter,
¢ aa¢ O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC.
m LL requires the applicant for such permit to file a signed statement that TOTAL E MIT
u whe is licensed pursuant to the provisions of the Contractor's License
rii Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe
¢ Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢t$ the basis for the alleged exemption.Any violation of5ection 7031.5 STORI S TYFE CONSTR.
A _ by any applicant for a permit subjects life applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($500).):
❑ 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 ProfessionsDRAINS-FLOOR,ROOF,AR CON O. 5.00
Code:The Contractor's License Law docs not apply to an owner of -
• properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 50.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,One owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or in,. R IND CON PB Gone,
for purpose.ofsale.). 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 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 contracloos)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contfaclrfs License Law. TRACTNO. PARCELNO.
reas❑ I am exempt under Sec. ,B.XP.C.lin this WATER HEATER W/VENT 6.00
on
Owner Data WATER SYSTEM 5.00 ACC.OATE ACC,FILE NO.
WORK ERS'COMPHNSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hefeby 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 Ihere ,Lab.C.),
Policy No mpan•� te_Com tion
0 ❑ C liliedc rykhemb $11.,d FIRE SPRINK 'ENERGY T-74
.❑ Cc ti(icd o is d WF�>1Fj• s'eWLlFj division.
Z p Applicant_ ' MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
~ va PERMIT ISSUANCE 10.00 FLOODZONE 'A.L.U.C.
C' 1'IPICATEO�-.I OPTION FROM WORKERS'
LOU COMPERSA'I'ION INSURANCE, PLG.CONTR. LIC.NO. PLG.
� Z I'm s section need not be completed if line permit is for one TOTAL v❑ N❑' Y ❑ N❑
hundred dollars(S 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 F mit is issued,1 shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
0 y Dale Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE '10 APPLICANT: If,after making this Certificate of Ex-
F Z emptimn,you should become subject to line Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions' o1' the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deenned revoked _ AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I 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.C.). 1 HEATING UNIT(TO 100,000 B.T.U-) 8.00
Lender's Name HEATI NG UN IT(OV ER 100,000 B.T.U.)9,50 ELECTRIC
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the 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.
Cu
pl:rf agar liabilities,jud ls, costs and expenses which CONST.TAX
may any way accrue agai id City in consequence of clic PERMIT ISSUANCE 10.00 10.00
giant g of this at. MECH.CONT. LIC.NO. TOTAL 18-001
� TOTAL
gnalu Applican /Contra- r 26-Wired/
OFFICE COPY