8858 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
Bl11LaLNG '�+ 5 APPLICATION & PER
A onuss
-e. BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
8858
OWNERS PLAN CHECK VALIDATION
E x�r/� OTY. ELECTRIC PERMIT FEE
�. 'C�` PHON
CONTRACTOR ' OUTLETS-SWITCHES-RECEP 10,00/1.00
(„ IIC.N-"4:113 a7 LIGHTING FIXTURES 10.00/1.00 -'
ADDDRESS
CONTRACTOR APPLIANCES-RESIDENTIAL 4.00
q PHON � PANELS 10.00 2O DATE OF APPLICATION
AAFG.TECT.So, Q{V'�- 9�+ PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER C\J 1
LIC,NO. SIGNS TRANS. 3.00
A CH ,OR ENG SPECIALCIRCUIT 5,00 (J PERMIT VALIDATION
SS
ZIP EMP.METER OR POLE INS. 20.00
APPLICANT'S / /l/A•-".'��
ADDRESS MOTORS SEE FEE SCH. G
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DHCLARATION TEMP.POLE 30.00
a u v I hereby affirm that I am licensed under provisions of Chapmr 9
w Q T (commencing with Section 7000)of Division 3 of the Business and ISSUANCE GATE
_ D z Professions Codicila license is in full for d
BLOC. ELECT. PLG. MECH.
z o w License Cla1L_Lie.Number
4 m r
Date-L (5_NI Contractor
w a 1O OSWINFR-BUILDER DECLARATION
JUNi) - " .1 BUIL*DING,PERMIT; ,.
o a O MISC.- REFER TO ORD INFORMATION'
X R. LL r 1 hereby affirm that I am exempt from the Contractor's License "
I- LL o v, Law l'or the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE VALUATION $/FT.
Code:Anycity orcoanty which requiresa permit to construct,alter, Q
Q Q Improve,demolish,or repair any structure,prior to Its Issuance,also ELEC.CONTE. LIC.NO. ELEC.
O LL requims the applicant for such permit to file a signed statematt that TOTAlc2 v,O_
PERMIT TO
n w $ he is licensed pursuant to the provisions of the Contractor's License
H z > Law(Chapterand
Professions
de) lit Section is exempt theion3 and
E o Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE -
M r- o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i ; m by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500).):
❑ 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 lite structure is not
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 dmough his own employees,provided that such impmvo
merits are not intended or offered for sale.If,)'..ever,the building GAS-EA.SYSTEM-1 1 NC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or im. GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for 1,as ownerose
of the.). RES INDUSTRIAL WASTE INTER. 30.00 1:1
I❑ ❑N ❑ ❑'
❑ d as owner of the property,am exclusively contracting with
licensed contractors oc to construct the project(Ser.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO,
and Professions Code:The who
License Law does not apply
to tr owner of property who builds tr improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such Lice
s with a contractors)licensed pursuant to
the Col am exempt
License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Ser,-,B&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKF-RS'COMPENSATION DECLARATIONWATER TREATING EQUIP, 5.00
1 hereby affirm that I have a certificate of consent to self-insure, s
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy there Lab.CK����
Policy a nnpeny
O ❑ Certified Copylsherebyfu ntsjm FIRESPRINK ENERGY T-24
Z ZC.,Iifi�p copy is filed with the city inspection div`sion.
O A plicant t/!!. P. MISC.- REFER TO ORD. Y E3 NE] Y El NE]
y Ce R'fIFICATIi OF EXIiM PTI(lN FROM WORK LRS' PEflMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LL > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG,
EL O (This section need not he completed if the permit is for one TOTAL Y❑ NY ❑ N�
Z 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 FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Lows of California.
O La Date Applicant ALTER OR ADD TO MECH. 5.001BUILDING
>- m NOTICE TO APPLICANT: If,alter making Dlis Certificate of Ilx-
F 2 emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with U FEE such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10,000C.F.M) 4.00
CONSTRUCTION LENDING AG1iNCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency lox EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(See. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
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
.1sive-mens ncil representatives ec this city Io enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mcntiorizeproperty for inspection purposes.
( a) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cup tiro against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
gr' lingofthispenni 1. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Ipn Pure of ApplicaRuciantractor Date
OFFICE COPY