8795 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
'BU I LDING PROJECT I DENTI FICATION- PERMITNUMBER
I.UILDING APPLICATION & PERMIT. 8 7 ^r '
ARRRESS y� nn `�' "
ONE K �s (l�rS ILIAC BUILDING-ELECTRICAL-PLUMBING-MECHANICAL J
OWNER'S PLAN CHECK VALIDATION
T' NAM/EA GG'���,� a% OTV. - ELECTRIC PERMIT -FEE
' M EA JV 1G r%L PHONE
CONTRACTORS
NAME UTLETS-SWITCHES-RECEP 10.00/1.00 '
p
1/M C q AAA/ f�1BC`IC.No. 26691 LIGHTING FIXTURES 10.00/1.00
ADDRREssroRs - ^ 15iw�5t CIA -- , APPLIANCES-RESIDENTIAL 4.00
IS01)0 W OOcIAr�n"0 PHONE 3��4//pQ PANELS - 10.00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP)- 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
AARCH,OR DDRESS.ENG SPECIALCIRCUIT 5.00 PERMIT VALIDATION
zIP ' EMP.METER OR POLE INS. 20,00 n
APPLICANTS
ADDRESS ' MOTORS SEE FEE SCH.
SERVICECHANGE 20.00
w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00• S��-r '
Q v U 1 hereby affirm Thal I am licensed under provisions of Chapter 9 I DAN DATE
y Q'y (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F w i Professions Code/rand my license is"'full fit a effec.� ❑ ❑ ❑
'e i m .License Class_r,^-7.(y_Lia Numbe _`j.,]
9 m f 91a1e�(_A-6'.r��Contractor�J�y�'s�' '
m L/ BUILDING PERMIT
¢ ¢ ¢ OWNER-B UILDF;R DL ARATION -
a aINFORMATION
X ; w H 1-hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
LL o ei Law for the following reason. Sec.7031.5,Businessand Professions VALUATION $/FT.
H _ h ( PERMIT ISSUANCE 10.00
f '" >f Code:
e,demyor countywhichany requires epermit oitOnsfr¢Laheq
¢ Q R O improve,demolish,or repair any structure,prior to its issuance,also ELEC.GDNTR, LIF N0. ELEC.
G u requires the applicant for such permit to file signed statement that _ TOTAL
u PERMIT TO
F:
m he Is licensed pursuant to the provisions of the Contractor's License
H z i
Law(Chapter 9(commencing with Section 7000)of Division 3 elite
4 o Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE '
¢ H the basis For Ilse alleged exemption.Any violationmf Section 7031.5 , STORIES , TYPE CONSTR.
d3 - by any applicant for a permit subjects the applicant IRS civil penally ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500)J:
❑ 1,as owner of the property,or my employees with wages us BACKFLOW PROTECT. DEV ICE 4.00 . .dt• OCe.'GROUP RES.UNITS
their sole compensation,will do the work,and the structure is lot t
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:'rhe Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SQ FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedfarsule.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of Completion, the owner GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 I
builder will have the burden of proving that he did 1101 build or inn .BUILDING USE
prove for purpose of sale.). RES IND CON Pe Other
❑ I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 11 ❑ ❑ 0 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 (EA.) 1.00
contracts for such projects with it umtractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10,00
the Contmclor's License Law. TRACT NO. PARCEL NO.
O lam exempt under Sen-,B.A.P.C.for this WATER HEAT T 1. 6.00
reason
Owner - Date WATER SYSTEM - 5.00
ACC.DATE ACC.FILE NO..
WORK F:RS'COM PENSATION DECLARATION WATER TREATIFe�upertlflo 5.00 '
1 hereby affirm that I have a certificate of consent to mirinsure. - -
or a certificate of Workers'Compensation Insurance,or a certifies) ZONING ENG.SITE NO.
copy thereof(Sec,3800,Lab.C.). ,
Policy No. Company
Q ❑ Curti' dcopy is hereby furnished. - FIRESPRINK ENERGY T 24
_ Z Z Cerf d cop 1 I to city inspection division.
O pliant C - MISC.- REFER TO OR D. Y� N� Y0 N�
~ rn . . PERMIT ISSUANCE 10.00
LU R'I'I I CO MPENSA EMPTI INSURANCE
WORK ERS, FLOOD ZONE A.L.U.C.'
-, W � COMPIiNSATION INSURANCfi PLG.CONTR. LIC.NO. PLG. !rFFE
7
CL a ffhi'�wction need not be completed if the permitris for one ' - TOTAL V Y❑ 'N[ 'Y❑ N
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per. CITY. MECHANICAL PERMIT
FEE SUMMARY
0 U out is issued.I shall not employ any person in any manner ash as m
become subject lot he Workers'Compensal ion Laws of California.
Q y Date Applicam - BUILDING
} N NOTICE TO APPLICANT: if,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
F 2 emptier,you should became subject td,the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwilh comply with FEE
U ouch provisions or this pennil shall be deemed revoked AIR HANDLING UNIT(TO 10=C-F.M.) 4.00
CONSTRUCTION LENDING AGENCY" AIR HANDLING UNIT(OVER 10MC.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.). HEATING UNIT(TO 100,000 B.T:U.) 8.00
Lender's Name H EATING U N IT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that l have read this application and state that the aboveVENTILATION FAN (SINGLE) 4.00
ordinances n correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state lows relating to building construction, and
hereby authorize representatives of this city to enter upon the BOI LER-COMP (Over 100,0110 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree I. save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupe lino against liabilities,judgnhents, coats Slid expenses which PERMIT ISSUANCE 10.00 CONST.TAX
ma 'n any way Scenic against said City in consequence of filo
gra ng of this pe it MECH.CONT. LIC.NO, MECH.
TOTAL TOTAL
a ore of Applicant/Cont ctor Date -
- OFFICE COPY '