09554 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -.USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION#i-PERMIT
AD 2= 66 _ b�, 09554
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
is R'S - PLAN CHECK VALIDATION
ECITY. ELECTRICePERM1T FEE
PHONE
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CONTRACTORS
! Lry£�F�F4ac� OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S 5» J44 PPLIANCES-RESIDENTIAL 4.00
ADD FSS
/4p
2 PHONEgB�Ht1r PANELS 10.00 DATE OF APPLICATION
ARCHITECTOR PLAN(OVER 200 AMP), 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.C.No. SIGNTRANS. 3.00
ARCH.
DRESS ENG SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPucnNr•s MOTORS SEE FEE SCH.
AgopfFr„ ��`'► SERVICE CHANGE 20.00
o 0 1''77(�(LICENSED CONTRACTORS OECLARATIIO-N, TEMP.POLE 30.00 "/U
a v u I hereby affirm that I am licensed under provisions of Chapter'I &�r 01� PAID ISSUANCE DATE
H m (commencing with Section 7000)of Division 3 of the Business and
w rt N BLDG. ELECT. PLG. MECH.
7 z Professions Cod ynd yLlieense is in full fur a J If - ❑ ❑ ❑
O0 o EO,"11121l, V Lia Rmrdrr A '�s 1,r
Date-E;�Contractor li V G �.-
< M s BUILUING.PERMIT
¢ ¢ w OWNER-BUILDER DECLARATION
X 3 u y I hereby affirm Del l am exempt from the Contractor's License MISC.- ♦�Q INFORMATION
r u o J Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE10 00 d e VALUATION
Code:Any city or colmly which requires a permit to construct,alter,
¢ ¢ 00 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. w
o ¢ requires the applicant for such permit to file n signed statement that TOTAL 30 u w $ he is licensed pursuant to the provisions of the Contractor's License PER MIT TOMI
H z i
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
4 o Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
ez I- the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
u3 by any applicant fore permit jecrs the applicant roacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred d.dollars(5500).):
❑ 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, Baniness and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5,00
Code:The Contractor's License Law does not apply to on owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
• himself re through his own employees,provided that such improve-
meimprov not mens is
old w thinoffered
onefor
year
If,however.tireobuilding GAS-EA.SYSTEM-1 1NC.4.OUTLETS 6.00
or der will
is sob within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
buildcr will have the burden of proving that he did not build or no. BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ I,as owner of the property,am exclusively contracting with ❑ O El ❑ El
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Coda: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 contractous)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt muter Sec.-,B&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION D17CI.ARATION WATER TREATING EOUIP. 5.00
1 hereby affirm that I have a certificate ofconsenr to self-insure, -
or a.ertif¢ate of Workers'Compensation Insurance,or a certified ZONING- ENG.SITE NO.
copy thereof(Sec.3A00,Lah.C.).
Policy No. Company
O ❑ Certified copy is hereby fumishrd. FIRE SPRINK ENERGY R24
Z Z ) ❑ Certified copy is tiled with the city inspection division. MISC.- REFER TO ORD.
♦- Applicant Y ❑ N❑ Y 0 No
D: a CERTIFICATE OI'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FL000 zONE A.L.U.C.
LL > COMPENSATION INSURANCE PLG.CONTR. LIC.No, PLG.
CL Z( This section need not be completed if the permit is for one TOTAL v N Y N
hundred doll.,,(S 100)or Ii
L) O 1 certify that in the performance of the work lin which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not em w0y �a,, it any manner so as to
Q W bcco}}ppgg c llwWor os,
^o , 'on�lws California. " [5
y Dut:r�L�,\pplica ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTI TO APPLICAN'P: If,ulcer mak rg this Certificate of Ex-
F Z emption,you should became subject to the Warkers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
C.1 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C,F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.EM.) 6.00 SEISMIC FEE
1 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 HEATING UN IT 100,000 B.T.U.)9.50 3. 0
Lender's Address ELECTRIC I C
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information is state. 1 agree to comply with all city and county BOILER-COW 13 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
m
ordinances and orate lows relating building construction, and
hereby authorize
iz thorizproperty for inspection purposes.
e representatives of this city to enter upon the
aboveh BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cu ,lino against liabilities,judgments, costs and expenses which CONST.TAX
'y t an y rue onsl.said City in consequence of the PERMIT ISSUANCE 10.00
gr n[ing nit. � .., MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
SUMITI,o pp' nl/Contractor to
OFFICE COPY