4700 APPLICANT.TO FILL IN INFORMATION WITHIN RED LINES - USE, BALI_ POINT PEN ONLY , .
BUI LDING PROJECT I DENTI FICATION PERMIT.NUMBER
.DILDIND -.
APPLICATION & PERMIT - 4700
AD DRE 5 /_ :
i a E[� NR•2T 1`V' r BUILDING -ELECTRICAL-PLUMBING_MECHANICAL
OwNERq-
'S V _ PLAN CHECK VALIDATION
ME % '1- TY. ELECTRIC PERMIT FEE
��. QnR � - lil:►FQ PRDNE
R Z�2 -ZO 4
aNTRAcroRs 'OUTLETS-SWITCHES-RECEP 5.00/1,00
NAME
LIC.NO.
LIGHTING FIXTURES 5.00/1.00
- CONTRACTOR'SAPPLIANCES-RESIDENTIAL 4.00
ADDRESS
LLPRONE PANELS 5.00 DATE OF APPLICATION
IJ ARCHITECTSIGN$ 6.DD `PLAN CHECK FEE P.C.NO.
OR
ENGINEER r
' sec.No. � - SIGNS TRANS. 3.00
ARCM.08 ENG. - SPECIAL CIRCUIT 5.00 TM1I� PERMIT VALIDATION
ADDRESS V ��
elP TEMP. METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
' - SERVICE CHANGE 10.00
w 0 o LICISNSFDCONTRACTORSDIiCI.ARA'I'ION I ,
a u U I hereby affirm that I am licensed under provisions of Chapter 9 _ ISSUANCE DATE
H Q H (commencing with Section 7000)of Divi ion 3.f the ILnsiness and BLDG. ELECT. PLG. MECH.
P, m z Professions Code,and my license is in full force and effect. ❑ ❑ ❑ ❑
z 0 m - License Class Lic.Number
C, - Dote Contractor
¢ y f - BUILDING PERMIT .
ir w ¢ OWNER-BUILDER DECLARA'T'ION " '
E o A. ° - MISC.- I 0 0� tl•10T0 ORD INFORMATION
w 4 1 hereby affirm that I am exempt from the Contractors License
F a. oi Law forthe followinlot.on.(Sec.7031.5,Rusinessand Professions PERMIT ISSUANCE 6.00
VALUATION $/FT.
Code.Any city.,county which requires.permit to construd,alter
a ¢ G p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
G u requires the applicant forsuch permit to file a signal statement that TOTAL �� PERMIT TO
a w m m he is licensed pursuant to the provisions of the Contractor's License
rzr
Law(Chapter 9(commencing with Section 7000)oflJivision 3 critic
¢ Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ F $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n3 � by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 4.00
of not more than five hundred doll...(S500).): ,
❑ 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 not
intended or offered for sale (Sec. 7044, Busines and Professions DRAINS-FLOOR,ROOF,AREA,COND, 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who Aces such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTALALREAGE
meats are through his own employees,provide)that such improve- _
himself o through
ot or offered emploeesale.provided
that such
building GAS-EA.SYSTEM-11NC.4OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM.OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im PES ID CON PB Other
prove for purpose ofsale.). _ INDUSTRIAL WASTE.INTEN
R. 20.00 El IN El❑ 1,as owner of the property,am exclusively'contracting with 0 El
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 docs not apply ,
I<„C to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5'IEA.) 1.00
contracts for such projects with a contractorls)licensed pursuant to
the Contractor's License SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCELNO.
IT lam exempt und Sec. ,B.&P.C.for this WATER'HEATERW/VENT 4.00
reason I
Dat( ',,;L-' Owner,4I_ WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Instomice,or u certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company `
.0 Certified copy is hereby furnished ' FIRE SPRINK ENERGY T 24
Z 2 ❑ Certified copy is fled with tine city inspection division. MISC.- REFER TO ORD.
0 Applicant - - Y ❑ 'N� Y ❑ NEI
~ y - - .00
PERMIT ISSUANCE - 6
_ CERTIFICATE 01'EXEMPTION 17ROM WORKERS' FLOOD ZONE A.L.UA.
IL COMPENSATION INSURANCE PLG.CONTR. LIC NO. PLO.
D. 0 ' ('this section need not be completed if the peord'is for one TOTAL V[:] N� V � N�
D Z hundred doll...($100)or III -
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 Is.as to
U become subject to the Workers'Compensation Laws of California BUILDING
y Date Applicant ALTER OR ADD TO MECH. 4.00 '
} N NOTICE JO APPLICANT: IL after making this Certificate of lix-
~ ? emption:you should become subject to the Workers'Compensation APPLIANCE' 4.00 PLAN CHECK
provisions-of (lie Labor Code, you must forthwith comply with, FEE
U. ' such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.)'5.00 'SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance cf the work for which this permit is issucA(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ.C.) _
Lender's Name HEATI NG UN IT(OV E R 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address .,..J
ICertify;that l have read this applicatiIhi and auto that the shove VENTILATION.FAN (SINGLE)- � 3.00
infornalion is correct. I agrte'to comply wifh':dl city and enunty - PLUMBING
ordinances and state laws relating to building constn¢tion, unit BOILER-COMP(3 H.P.or 100,000 B,T.U.) 4.00
hereby authorize representatives of this city to enter upon the
abovementioned'property for inspection purposes. BOILER-COMP IOvar'100,000 BTUI SEE PEEBCH. MECHANICAL ^
(We)•agree to save„indemnify and keep hannless the City of MISC.- REFER TO ORD.
mo
againei iiablll[ies,judgmm s, coxa and expense,which - CONST.TAX
may y-xey-rte'Zc"
ag.inat sold 'n consequence of the PERMIT ISSUANCE 3.00
t go ,n • MECH.CONT. LIC.NO.
TOTAL TOTAL
Igndturo of Applicn ontrudor Uulo -
A r - 'OFFICE COPY