16321 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT-PEN ONLY
. BUILDING PROJECT IDENTIFICATION PERMITNUMSER
•aG,LD,N // C �/ APPLICATION & PERMIT ' 1632.1
AUDR Sn:3.2
3. J � �I//� t.7
OOT/ BUILDING-ELECTRICAL-PLUMBING-MECHANICAL f•
1 ..NED S, � T L-- PLAN CHECK VALIDATION
NA!TI w( v 4Ck,S )Y ,PHONE ' DTV. ELECTRIC PERMIT FEE -
�' CONTRACTORS - p OUTLETS-SWITCHES-RECEP 10.00/1.00 '
/ L �✓��- uc.No. /Z/ `- LIGHTING FIXTURES .10.00/1.00 -
CONTRACTOR 0W +� - APPLIANCES-RESIDENTIAL -4.00 '
AD
DRE55 /J
.Sy 3 �A�-0$//RrP/k5 PRDrvE J/Sj c.2� PANELS: , 10.00
DATE OF APPLICATION
OgCRITECT PANELS (OVER ZOO AMP) 20.00 PLAN CHEC7 P.C.NO. -
ENGINEER
LIC.NO. .% SIGNSTRANS. . - 3.00
ARC-O.ENG , - PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT - - 5.00 '
ZIP EMP.METER OR POLE INS. .0000 (}-
APPLICANT'$ '
ADDRESS s M)N1t` - MOTORS SEE FEE SCH.
.SyB-� A�OJ (�PQQB/ S,GfOIy, SERVICE CHANGE - - 20.00 p / Q/�'
(co
r O o LICENSED CONTRACTORS DECLARATION b
< w I mmencing with SeC tion 7000)of Division 3 of the Business rued hereby affirm that I am licensed under provisions of Chapter) '
G < u I&NC DATE
BLDG. ELECT. 1. PLG: MECH.
H y i Professions Code peed my licenu is in full for�yen�pf' t.
o z.w d Lice C Lr1y (acs�V Lia Number/ + _
H H Uate - /�N Lic Net
'L
wa OWNER-BUILDER DECLARATION -
BUILDING PERMIT
w °nQ re MISC- ''s" REFER TO ORD a INFORMATION
,; N I hereby al firm that am exempt from 11te Curitractor's License
u 6oj Law for the following reason. 7031.5.Business and Professions VALUATION $/FT.
- PERMIT ISSUANCE _
m was Cnde:Anymiry nrcounty pair any structure peior lo'i issuance,ttCT,also kpJ
a0 O improve,demolish;oT repair any sVucture,prior toils issuance,also ELEC.CONTR. LIC.NO. - ELEC V B71
u requires the applicant for such permit to file a signed statement License
TOTAL -eC_---_�
a w he is licensed pursuant to the provisions of the Contractor's Licenu C7`y'tjGY�yyLCU(r/N
Hi
Law with Seelion 7000)0 fDivision 3 ofthe - -
i o business and Professions Code)or thal,he is exempt therefrom and OTV. PLUMBING PERMIT FEE
Q
an es the,basis forlhealleged exempt ion.Any violation ofSection703L5 - STORIES TYPE CONSTR.
by any applicant for a pertnit suhJecls the applicant to civil penalty
of notmor.than five hundred dollars($500).): ALTER-DRAIN&VENT-WATER.(EA.) 5.00
❑ I,as owner of Om property,or my employees with wages as
tireBACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
d sole compensation,will do the work,and the structure is not - s
intended or offered far Sale`(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,CON D. 5.00
Code:The Contractor's Liecow Law does not apply to an owner of
• properly who builds or Improves thereon,and whodoes such work FIXTURES-PER TRAP ' - 5.00 SQFT.FLOORAREA TOTALACREAGE
Iii...self oi'fhnntgh his own employees,provided find sueh for e-
mentsare nor intended oroffined forsale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS '6.00
or improvement is sold within ane year of completion, the owner- GAS EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the.hurden of proving that h -e did not build or im- BUILDING USE
pmvebmtemp.W.fsale.). INDUSTRIAL WASTE INTER:' 30.00 RES IND CON PB Dme,
O I,as owner of lite properly,am exclusively contracting with 0
licensed can,,,C.d to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 - ASSESSORS PARCEL NO.
and Professions property Contractor's improro S th dues nm apply -
- to tr owner of property who builds or improves rased ll,and who LAWN SPRINKLERS-OVER-5 IEA.) 1.00 the
Co ds for such projects with a condracdor(sl licensed Pursuant fo
the 1ani xerri-i under
Law. SEWER-SANITARY-STORM EA.200ftI10.00 TRACT NO. PARCEL NO.
❑ I';mn exfnal under Sec. _ ,N.&P.C.for this WATER HEATER W/VENT 6.00
reason
Ownerr, ume WATER SYSTEM 5.00 ACC.DATE + ACC.FILE NO:
W'ORKFRS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
- - I hereby affirm that I have a certilicate of consent to self-insure,
or a certificate or Workers'Compensalion Insurance,or a cerllfied ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.). ,
Policy No. Compan - -
0rx 0 Cc if i'h re furnished. FIRESPRINK - ENERGYT@4
Z Z �' Certifi d' with lire city inspeclion division.
A{+pl'icant MISC.- REFER TO ORD. Y N� v NO
ir y CERTIJCATF OF EXEMPTION FROM WORKER S' . PERMIT ISSUANCE 1 R.0.00 FLOOD ZONE 'A.L.U:C.
LL > COMPENSA'T'ION INSURANCE PLG.CONTR _ 71C.NO. - PLG
4' O (This section need not be completed if the permit is for .one TOTAL Y N� Y"[:]- N�
Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- OTV. MECHANICAL PERMIT _ FEE FEE SUMMARY
LL in D 0 U become subject n t the Wark Rlsl,ib Put SC tiny person
aws oij Cul Tornia ormer so is to
U a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
.
} m NOTICE TO APPLICANT: If,after making this Certificate of Ex- -
Z enation,you should become subject to the Workers'Campcnsalion APPLIANCE - _ .5.00 ' PLAN'CH ECK
provisions of the Labor Code, you must forthwith comply with - FEE
U such provisions or this permit shall be deemed revoked. _ AIR HANDLING UNIT(TO 10)ODOCF.M.) 4.00
CONSTRUCTION LEN DING AGENCY ' AIR HANDLING UNIT(OVER 10MOCEM.) 6.00 SEISMIC FEE
I hereby affirm that-thine 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.). H EATING UN IT(TO 100,000 BtT.U.) 8.00 -
Lender'sAddress
Lender's Address HEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ' ELECTRIC
I certify that I have read this applienlion and state find the above `}a VENTILATION FAN (SINGLET 4.00
- information is correct. I agree to comply with all city and county PLUMBING
ordinances and stale laws relating 10 building eons'traoi. , and BOILER-COMP(3 H.P.Or 100,000 B.T.U.)-6.00
hereby autenti orid roperty fori ins of this city to un ler upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL'
above-mentioned property for inspection purposes.
x '(We) agmt to save, indemnify-and keep harmless the City of 'MISC.- REFER TO ORD.
uperfino against habit es,judgments, costs and expenses which PERMIT ISSUANCE~ 1 10.00 CONST.TAX
W�yw cc agaist said City i conseruence of thew P '/}' 1MECH.CONT. + + LIC.NO. . '+ MECH:'OTAL TOTAL
Applicant/Contractor` Uafe � - •
\ - - OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT-PEN ONLY
. BUILDING PROJECT IDENTIFICATION PERMITNUMSER
•aG,LD,N // C �/ APPLICATION & PERMIT ' 1632.1
AUDR Sn:3.2
3. J � �I//� t.7
OOT/ BUILDING-ELECTRICAL-PLUMBING-MECHANICAL f•
1 ..NED S, � T L-- PLAN CHECK VALIDATION
NA!TI w( v 4Ck,S )Y ,PHONE ' DTV. ELECTRIC PERMIT FEE -
�' CONTRACTORS - p OUTLETS-SWITCHES-RECEP 10.00/1.00 '
/ L �✓��- uc.No. /Z/ `- LIGHTING FIXTURES .10.00/1.00 -
CONTRACTOR 0W +� - APPLIANCES-RESIDENTIAL -4.00 '
AD
DRE55 /J
.Sy 3 �A�-0$//RrP/k5 PRDrvE J/Sj c.2� PANELS: , 10.00
DATE OF APPLICATION
OgCRITECT PANELS (OVER ZOO AMP) 20.00 PLAN CHEC7 P.C.NO. -
ENGINEER
LIC.NO. .% SIGNSTRANS. . - 3.00
ARC-O.ENG , - PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT - - 5.00 '
ZIP EMP.METER OR POLE INS. .0000 (}-
APPLICANT'$ '
ADDRESS s M)N1t` - MOTORS SEE FEE SCH.
.SyB-� A�OJ (�PQQB/ S,GfOIy, SERVICE CHANGE - - 20.00 p / Q/�'
(co
r O o LICENSED CONTRACTORS DECLARATION b
< w I mmencing with SeC tion 7000)of Division 3 of the Business rued hereby affirm that I am licensed under provisions of Chapter) '
G < u I&NC DATE
BLDG. ELECT. 1. PLG: MECH.
H y i Professions Code peed my licenu is in full for�yen�pf' t.
o z.w d Lice C Lr1y (acs�V Lia Number/ + _
H H Uate - /�N Lic Net
'L
wa OWNER-BUILDER DECLARATION -
BUILDING PERMIT
w °nQ re MISC- ''s" REFER TO ORD e INFORMATION
,; N I hereby al firm that am exempt from 11te Curitractor's License
u 6oj Law for the following reason. 7031.5.Business and Professions VALUATION $/FT.
- PERMIT ISSUANCE _
m was Cnde:Anymiry nrcounty pair any structure peior lo'i issuance,ttCT,also kpJ
a0 O improve,demolish;oT repair any sVucture,prior toils issuance,also ELEC.CONTR. LIC.NO. - ELEC V B71
u requires the applicant for such permit to file a signed statement License
TOTAL -eC_---_�
a w he is licensed pursuant to the provisions of the Contractor's Licenu C7`y'tjGY�yyLCU(r/N
Hi
Law with Seelion 7000)0 fDivision 3 ofthe - -
i o business and Professions Code)or thal,he is exempt therefrom and OTV. PLUMBING PERMIT FEE
Q
an es the,basis forlhealleged exempt ion.Any violation ofSection703L5 - STORIES TYPE CONSTR.
by any applicant for a pertnit suhJecls the applicant to civil penalty
of notmor.than five hundred dollars($500).): ALTER-DRAIN&VENT-WATER.(EA.) 5.00
❑ I,as owner of Om property,or my employees with wages as
tireBACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
d sole compensation,will do the work,and the structure is not - s
intended or offered far Sale`(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,CON D. 5.00
Code:The Contractor's Liecow Law does not apply to an owner of
• properly who builds or Improves thereon,and whodoes such work FIXTURES-PER TRAP ' - 5.00 SQFT.FLOORAREA TOTALACREAGE
Iii...self oi'fhnntgh his own employees,provided find sueh for e-
mentsare nor intended oroffined forsale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS '6.00
or improvement is sold within ane year of completion, the owner- GAS EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the.hurden of proving that h -e did not build or im- BUILDING USE
pmvebmtemp.W.fsale.). INDUSTRIAL WASTE INTER:' 30.00 RES IND CON PB Dme,
O I,as owner of lite properly,am exclusively contracting with 0
licensed can,,,C.d to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 - ASSESSORS PARCEL NO.
and Professions property Contractor's improro S th dues nm apply -
- to tr owner of property who builds or improves rased ll,and who LAWN SPRINKLERS-OVER-5 IEA.) 1.00 the
Co ds for such projects with a condracdor(sl licensed Pursuant fo
the 1ani xerri-i under
Law. SEWER-SANITARY-STORM EA.200ftI10.00 TRACT NO. PARCEL NO.
❑ I';mn exfnal under Sec. _ ,N.&P.C.for this WATER HEATER W/VENT 6.00
reason
Ownerr, ume WATER SYSTEM 5.00 ACC.DATE + ACC.FILE NO:
W'ORKFRS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
- - I hereby affirm that I have a certilicate of consent to self-insure,
or a certificate or Workers'Compensalion Insurance,or a cerllfied ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.). ,
Policy No. Compan - -
0rx 0 Cc if i'h re furnished. FIRESPRINK - ENERGYT@4
Z Z �' Certifi d' with lire city inspeclion division.
A{+pl'icant MISC.- REFER TO ORD. Y N� v NO
ir y CERTIJCATF OF EXEMPTION FROM WORKER S' . PERMIT ISSUANCE 1 R.0.00 FLOOD ZONE 'A.L.U:C.
LL > COMPENSA'T'ION INSURANCE PLG.CONTR _ 71C.NO. - PLG
4' O (This section need not be completed if the permit is for .one TOTAL Y N� Y"[:]- N�
Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- OTV. MECHANICAL PERMIT _ FEE FEE SUMMARY
LL in D 0 U become subject n t the Wark Rlsl,ib Put SC tiny person
aws oij Cul Tornia ormer so is to
U a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
.
} m NOTICE TO APPLICANT: If,after making this Certificate of Ex- -
Z enation,you should become subject to the Workers'Campcnsalion APPLIANCE - _ .5.00 ' PLAN'CH ECK
provisions of the Labor Code, you must forthwith comply with - FEE
U such provisions or this permit shall be deemed revoked. _ AIR HANDLING UNIT(TO 10)ODOCF.M.) 4.00
CONSTRUCTION LEN DING AGENCY ' AIR HANDLING UNIT(OVER 10MOCEM.) 6.00 SEISMIC FEE
I hereby affirm that-thine 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.). H EATING UN IT(TO 100,000 BtT.U.) 8.00 -
Lender'sAddress
Lender's Address HEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ' ELECTRIC
I certify that I have read this applienlion and state find the above `}a VENTILATION FAN (SINGLET 4.00
- information is correct. I agree to comply with all city and county PLUMBING
ordinances and stale laws relating 10 building eons'traoi. , and BOILER-COMP(3 H.P.Or 100,000 B.T.U.)-6.00
hereby autenti orid roperty fori ins of this city to un ler upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL'
above-mentioned property for inspection purposes.
x '(We) agmt to save, indemnify-and keep harmless the City of 'MISC.- REFER TO ORD.
uperfino against habit es,judgments, costs and expenses which PERMIT ISSUANCE~ 1 10.00 CONST.TAX
W�yw cc agaist said City i conseruence of thew P '/}' 1MECH.CONT. + + LIC.NO. . '+ MECH:'OTAL TOTAL
Applicant/Contractor` Uafe � - •
\ - - OFFICE COPY