4443 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
' / BUILDING APPLICATION:& PERMIT '
-7 a°DREa6 �/
BUILDING-ELECTRICAL-PLUMBING -MECHANICAL 4443
OWNER'S i - PLAN CH ECK VAL IDATION
NAME I [ /`Q QTY. ELECTRIC PERMIT FEE
L L PNONC)_1 E / �Fol .
NAmellacTDRs OUTLETS-SWITCHES-RECEP 5.00/1.00
REss L'LIC NO. LIGHTING FIXTURES 5.00/1.00
A0DALa°qs APPLIANCES-RESIDENTIA4.00
anon E
PHONE PANELS 5.00 DATE OF APPLICATION
ARRCHITECT SIGNS _ 6.00 PLAN CHECK FEE P.C.N0.
ENGINEER
'uc.NO. SIGNS TRANS. 3.00
ADD Ess ErvG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP ITEMP.METER OR POLE INS.- 15.00
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00 / dg 3
o
a LICENSED CONTRACTORS DECLARATION 0
¢ u u I hereby affirm that I um licensed under 1100sions of Chupter'J ISSUANCE DATE
y Q n (commencing with Section 70001 of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
o z Professions Code,and my license is in full force and effect.
O i V a License Class Lic.Number
ut r Data Contractor
m BUILDING PERMIT
¢ ¢ w OWNER-BUILDER DECLARATION
w °; LL y 1 hereby affirm that I am exempt from the Contractors License MISC.- REFER TO ORD I RMATION
HaoJ Law for the followingreason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00 AU $/FT.
Code:Any city or county which requires a permit to UnotracL alley, deo �
SE a, improve, or repair any structure.priorlo itS issuance,also ELEC.CONTR. LIC.NO. ELEC. /4
O ¢ requires the applicant for such permit to file a signed statement that TOTAL
w'$ he is licensed pursuant to the provisions of the Contractor's Liranse
Law(Chapter 9(commencing with Section 7000)ofDivision3 of(heVy�-111
E z c Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ r o the basis for the alleged exemption,Any violation of Section 7031.5 T T.,VE CONSTR
P .
a ';;'' by any applicant a permit subjects the applicant to e civil penalty ALTER-DRAIN -WATER (EA.) 4.00 � 'RIES�7 Ig' /
of nol mom than fivehundred dnllarsfS5001.):
❑ L 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, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Cole:The 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 4.00 50.FL FLOOn aREa TOTAL ACREAGE
himself re through his own employees provided o that such improve-building
mems are not intended or offered lot sale.If,however,the building GAS-EA.SYSTEM-l1NC.40UTLETS 4.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1 m BUILDING USE
builder will have the burden of proving that he did not build or an-
RES IND CON- PB Other
prove for purpose of sale.!. INDUSTRIAL WASTE INTER. 20.00
❑ d as owner of the property,he Project
(Sc .attracting with
licensed colons Codi° constructthe project(Sec.7044,Business LAWN SPRINKLERS-1 INC5V.B.' 5,00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law Joos not apply
to anowner of property who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts forsuchn,jec with ncontmalnr(s)IieenseA purxunnt to SEWER-SANITARY-STORM EA, 200ft8.00
'
the COrtntmclors License
L
cnsc Low. / TRACT NO, PARCEL NO.
❑ tum exempt under Sec.-,B.&RC.for this WATER HEATER W/VENT 4,
reason 00
Data �(,'/=�(L-�f�_Owner _ WATER SYSTEM 4.00
ACC.DATE ACC.FILE N0.
WORK ERS'COSIPENSA NON DECLARA'r ON WATER TREATING EQUIP, 4.00
I hereby affirm that I have a certificate ofconsent to self-insure,
or a certificate of Workers Compeasullon Inounnev,or u certified ZONING- ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.L -
Policy No. Company
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z Cl Certified copy is filed with the city inspection division. - ,
O Applicant MISC,- REFER TO ORD. Y [] N❑ Y No
~ m - PERMIT ISSUANCE 6.00
LU CISRTIPICATEOPF,ATION'ION FROM WORKERS' FLOOD ZONE A.Lu.C.
W COMPIiNSATION INSURANCE PLG,CONTR. LIC.NO. PLG.
CL ffhis section need not he completed if the pennit is for one TOTAL Y❑ N[_ Y ❑ N
0 Z hundred dollars IS 100)or les.)
U O I certify that in the performance of the work for which alis per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued, 1 shall not employ mry person in my nu;nncr w ax to
Q U hero nv xubjeq to the Workers'Compensation Laws of California.
La Date-Applicant ALTER OR ADD TO MECH. 4.00 - BUILDING 33 , JJ6
} m NOTICE. TO APPLICANT: If,after making this Certificate of Ex-
F.Z eruption,you should hecome suhjcat to the Workers'Conlpena;rion 'APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must finthwuh 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
1 hereby affirm that there is a hick this
lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T,U.P.50
Lender's Address ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
Information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating m building conslructiim, and BOILER-COMPI3 H.P.Dr 100,000 B.T.U.1 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000BTU)SEE FEESCH. MECHANICAL
above mentioned property for inspection purposes.
(We) agree to save, indemnify and keep hmmlmx the City of, MISC.- REFER TO ORD.
Cu •mina against liabilities,judgments, ,t, and expenses which CONST.TAX
ITS
'n any lace a agai st sal C;ty in xeq uence of the PERMIT ISSUANCE 3.00
gr ng oflhiwt To MECH.CONT. L(C.NO. MECH.
-AA �_ �y TOTAL TOTAL 3 j [?U
Signutu fAppiicant/Contra.or Date �•�
- OFFICE COPY
I