12058 Ij?�91_ICANT'TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION - PERMIT NUMBER
BUILDING APPLICATION & PERMIT 12058
DD E
JC BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER' PLAN CHECK VALIDATION
Nnm r�-N LT/� J OTY. ELECTRIC PERMIT FEE
S �we A
Co DRS OUTLETS-SWITCHES-RECEP 10.00/1.00
NAM
/ Ic. GHTING FIXTURES 10.00/1.00
c NT cons PPLIANCES-RESIDENTIAL 4.00
ADD ss
OX E PANELS AID10.00 6 - DATE OF APPLICATION
RCHtiE PLAN CHELK FEE P.C.NO.
DR PANELS (OVER 200 AM 1 20.00
Ervcl SIGNS TRANS. C 11 f 3.00
AARCHDDRESS ENG. - SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER ORP I .00
APPLICANT'S MOTORS
ADDRESS E
SERVICE CH NG 0.00
wO o LICENSED CONTRACTORS DHCLARATION
a u v I hereby affirm that I am licensed under provisions of Chaptet 9 ISSUANCE GATE
n <N (commencing will,Section 7000)of Division 3 of the Business and _ BLDG. ELECT. PLG. MECH.
o Professions Codee, "d e9yJ1/ense is in full
z o T Lloe L(.(,C-Lic.NumbcR--S - ❑
o N r w U Comractor
M y s 4 � BUILDING PERMIT
0 i U U f:R-BUILDER DIiCLA RATION INFORMATION
w ; u w I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION
H u m J Law for the following reason.(Sec.703 1.5,Busincssand Pmfesaions PERMIT ISSUANCE 10.00 0 $/FT.
Code:Any city or county which requires a permit to construct,alter,
C Q p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. / //D
al D 0 requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w $ he is licensed pursuant to the provisions of the Contractor's License _
r z i Law(Chapter 9(commencingwith Section 7000)of Division 3 of the
4 Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
IS _ $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
is by any applicant for a permit subjects the applicant too civil penally ALTER-DRAIN (EA.) 5.00
of not more than five hundred dollars($500).).
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code: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 5.00 So FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve. GAS-EA.SVSTEM-11NC.40UTLETS 6.00
ments are not intended or offered for sale If,however,the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or me. BUILDING USE
RES. IND CON PB GO.,
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ d as owner of the property,he exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors nr construct the priced(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The who
o License Law does not apply
to tr owner of property who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contours for such Licenects Lwithacontrador(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
the Contractor's License Law.
❑ I am exempt under Sec. ,B&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dale WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
CLARATON nt to l WATER TREATING EQUIP. 5.00
r a c (kers'C /�� 1 cunsenl to self-insure, ZONING
or a certificate of Workers'Coope sation Irouonce,or a certil icA ENG.SITE N0.
copy thereof(Sec.38 ).
Policy ere-Company
O ❑ Certified copy is teteby furnished. FIRE SPRINK ENERGY T 24
Z Z Certified py file he cit rasp ton division. MISC.- REFER TO ORD.
F O AAkcant V❑ ry❑ y ❑ N❑
rn PERMIT ISSUANCE 10.00
- CE I AilEOFE PTION1'R ORKERS' FLOOD ZONE A.L.U.C.
LU > COMPF.N TIONINSUR CE PLG.CONTE. LIC.NO. PLG.
Q. O (This section recd not be completed if Ole permit is for one TOTAL Y❑ N❑ Y❑ No
Z) Z hundred dollars($100)or less.)
U 0 I certify that in the performance of the work for which this per. OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,1 shall not employ any person in any manner so as to
become subject to the Workeri Compensation Laws of California.
y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex.
F., Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
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 1QDOOC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency 1'nr EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATI NG UNIT(OV ER 100,000 B.T.U.)Lender's Address ELECTRIC //0
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cu a lino . �Ihat 'abilities, Idgme s, costs end er, arses which PERMIT ISSUANCE 10.00 CONST.TAX
ma s a m [ City cons �ence of the
granting r5 peon MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signature of Applicant/Can actor Data
COPY