6442 -ANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDINGPROJECT IDENTIFICATION PERMIT NUMBER
�.p. BUILDING APPLICATION & PERMIT
A D � �p�I1G�ll �r BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 6442
OWNER'S PLAN CHECK VALIDATION
" QTY. ELECTRIC PERMIT FEE• ']']s PHONE 113 J 33 �43 3 �� V
HANE ACTORS UTLETS-SWITCHES-RECEP 5.00/1,00
LIC,NO. LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'SPPLIANCES-RESIDENTIAL 4.00
A OORESs
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER
' uc.No. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00 ��
APPLICANT
s � MOTORS SEE FEE SCR.
ADDRESS
SERVICE CHANGE 10.00
0 0 LICIiNSEU CON"TRACTORS DECLARATION 7
P, u eat 1 hereby g it that I am licensed undervisionprovisionsote of Chapter,snd ISSUANCE DATE
P, <vAwi (commencing with Section 7000)of Uivision 3 Of the Business and BLDG. ELECT. PLG. MECH.
H H z Professions Code,and my license is in full force dad effect. ❑ ❑ 11 ❑
z 0. - License Class Lic.Number
LD zY H to Irate Contractor
a BUILDING PERMIT
¢ ¢w ¢ OWNER-BUILDER DECLARATION RMATION
MISC-- REFER TO ORD
u`xI;LL H I hereby at fvm that 1 am exempt from the Contractor s License A SIFT.
w_.. 0 sc Law Ib,the following reason.(Sec.7031.5.Business and Pones,um, PERMIT ISSUANCE 6.00
Code:Any city or county which requiresapermit Inconstruct,alter,
Qto Q 0 bnptove,demolish.or repair any structure.prior to Its Issuance,alsoELEC.CONTIi. LIC.NO. ELEC.
- 0 ¢ requires the applicant for such permit to file a signed statement that TOTAL E
a wis y he is licensed pursuant to the provisions of the Contractor License
Hzr Law(Chapter 9(commencing with Section 7000)of Uivision 3 ofthe .�TC' s dN�
- a Business and Professions Code)or that he isexempt therefrom and QTY. PLUMBING PERMIT FEE
¢ = $ file basis for the alleged exanplion.Any violation of Section 7031.$ 5 RI VPE CON STB.
.w by any applicant for a permit subjects the applicanito a civil penally ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(S5000.):
❑ 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GHOUP RES.UNITS
their sole conhperlsation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:'The Contract.,',License Law docs not apply to an owner of
Property who builds or improves thereon,and who docs Such work F IXTUR ES-PER TRAP 4.00 SQ IT.FLOOR AREA TOTAL ACREAGE
• himself or through lits own employees.Provided that such imporve-
mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
r improvement is sold within(tile year of completion,till:owner GAS-EASYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or vim .- RES IND CON PB Other
prove for purpose of sale.). INDUSTRIWASTE INTER. 20.00
y�� 1,as owner of the property,am exclusively contracting with ❑ E:] ❑ ❑ ❑
lit11inxd contract.... w rolutruct the project(Sec. 7044,Business LAWN SPRINAL KLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and P,.fessions Code:The Contractors License Law does not apply
m n
an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
condition,for such projects with it contructoos)licensed pursuant to
Bh•C Nmctor's License I. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
hum uxem funder Sec ,B.&Paco or this WATER HEATER W/VENT 4.00
I
e son IC�7�' hear_ 4_C114
uwnet 71 Date WATER SYSTEM - 4.00 EAAACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to self-insure, ENG.SITE NO.
or d certilicule of Workers'Compensation Insurance,or a cetlifiedcopy thereof(Sec.3800,LahC.l.Policy No. CompanyO ❑ Certiliedcopyishcrcbylumished, ENERGY T-24
ZZ ❑ Certified copy is Tiled with the city inspection division. MISC.- REFER TO ORD. Y ❑ N❑
nppBCant
PERMIT ISSUANCE 6.00 A.L.U.C.
Lu - CER'I'IFICCO OP Ii/I TINS FROM WORKERS'
L1J >_ COMPIiNSKI'ION INSURANCIi PLG.CONTR. LIC.NO. PLG.
Q. O ('I'I i, ,'ection need not he completed if the Permit is for one TOTAL v❑ N❑ Y❑ N❑
::) Z hundred dollar(5100)or less.)
U O 1 certify that in tile Performance of the work for which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued.1 shall not employ any person m any manner so as w
O w become subject to the Workers'Compensation Laws of California. 0
Date AIlPlicanl ALTER OR ADD TO MECH. 4.00 BUILDING l6G _
} N NO[ICIS'1'0 APPLICANT'. it,after making tills Certificate of lix-
? smplion,you sIt..uld become sonce,to the Workers'Compluend oo APPLIANCE 4.00 PLAN CHECK
provisions e-1the Luber Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=11F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000GEM.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency lin EXHAUST HOOD (WITH DUCT) 2.00
the perhbnnance of the work for which this permit is issued(Sec. MICROFILM
3097,CiYC.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Loodcrs Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Addrex
I certify that I have Tedd this application and stale that the above VENTILATION FAN (SINGLE) 3.00
inti rmatiou is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relining to building construction, and
herehy authorise representatives of this city to enter upon the BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
IWc mew save, in m ify anA keep harmless the City of MISC.- REFER TO ORD.
Cope no against iabiliY s,j Jgmenls,costs and expenses.[,fell CONST.TAX
may m way accru e, nst said City in -no,clu•nee of the PERMIT ISSUANCE 3.00
gral u f MECH.CONT. LIC.NO. MECH. S.V
S z/ TOTAL TOTAL 61 7
Si nalh sof plural b..tmctur D lc '
OFFICE COPY