16782 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICA710N
PERMIT NUMBER
BUILDING - APPLICATION & PERMIT � �+E]O
ADDRESS /1- U r o
Qridnauu, IWh/ BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
OWNEH'S I PLAN CHECK VALIDATION
rvAMFx I .OTY. ELECTRIC PERMIT FEE
E
NAMERACT R's 'OUTLETS-SWITCHES-RECEP 10.00/1.00 20
Ir NC. LIGHTING FIXTURES 10.00/1.00 1
ADORESS oes n,.V, APPLIANCES-RESIDENTIAL 4.00' � ��`�L��/
ADDRESS IC,LLA.
II PHDrvE
PANELS 10.00 DATE OF APPLICATION
ORRCHITECT PANELS (OVER 200 AMP) 20,00
PLAN CHECK FEE P.C..NO.
ENGINEER
LIc.No. SIGNS TRANS. 100
ARCH,ESS Ervc' I SPECIAL CIRCUIT 5.00 RBRNI ALIDATION
ZIP - EMP.METER OR POLE INS. 20.00 M Y
AVDRESS PLICANTTS MOTORS
ADSEE FEE SCH. I AN 141992
SERVICE CHANGE 20.00 ,
/�
CUPt HI IIVU
'02 LICENSED CONTRACTORS DECLARATION C OF a
I hereby uDlnn Ihul'I am licensed under Provisions of Chlgllcr 9 FINALEDAN ISSUANCE DATE
may, (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H y z Professions Codyy..and license ism full f a f r ❑ ❑ ❑
o z w p Licence—Class_(�i_I(,)__pL�icy.��N,u�my�b�er IE_
a so E Data rafiJWG � ,'2—/V//'
re ¢ w OWNER-BUILDER DECLARATI Z BUILDING PERMIT
E:
g.a H I hereby of irai that I am exempt from the Contractors License MISC.— D INFORMATION
FU0< Luwl'orthe followingrcasor(Sec.703L5,IfusinessanJProfessions PERMIT ISSUANCE VALUATION $/FT.
Codi Any city or county which requires a permit to construct,alter, 10.00
¢Q p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
o¢ requires the applicant for such permit to file a signed statement that TOTAL
u w he is licensed pursuant to the provisions of the Contractor's License PERMIT TO '
H z i Law(Chapter 9(commenciagwllh Section 7000)of Division 3 of the "
4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ H $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a by any applicant for a permit subjects the applicant ton civil Penalty ALTER-DRAIN So VENT-WATER (EA.) 5.00
Of not more than five hundred dollar,($500).):
D I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 400
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 docs such work FIXTURES-PER TRAP 5.00 so,FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such holoove-
• ments are not intended or offered for sale,If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
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 im- BUILDING USE
Prove for purpose Of sale.). ' RES IND CON PB Other
❑ I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 1:1 F-1 El El El
contractors In construct the project(Sec. 7044,Buxineas LAWN SPRINKLERS- 1 INC 5 V.g. 600 ' ASSESSORS PARCEL NO.
and Professions Code: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 it contractors)licensed Poorant to SEWER-SAN V-STORM EA,200ft/10:00
the Contractors License Law. TRACT NO, PARCEL N0.
❑ Irun exempt under Sec. ,B.&P.C.tilr this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO,
qp[Y'� }"% Py�y`kI ION IiECLARA'IAON WATER TREATING EQUIP, 5.00
1 terebY altlroi hat h ve a e Ifieate of consent to self-insure, ZONING
or a cerlificat Workers'Compensation Insyd}
ranC r a certified ENG.SITE NO.
copy thereof ec.3800,Lab,C 1 ,{��,,�/�
Policy No. Cnmpun �: '
0 O CertiBedcopy is hereby furnished.
Z Z VICertified ropy is fled with tireFIRE SPRINK ENERGY T-Z4 city inspection division. MISC.- REFER TO ORD.
O Applicant Y❑ N❑ ,Y ❑ N❑
CCN CERTIFICATE OP EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLO.CONTE. - LIC.NO, PLG. ❑ ❑ ❑ ❑
CL O ('this section need not be completed if the pet'nth is for one TOTAL Y N Y N
M Z hundred dollar,(SI00)or, less.)
U O 1 certify that in the performance of ilia work for which this Per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
U. F mit is issued,I shall not employ any person in any manner so a to
O La become subject to the Workers'Compensation Laws of California.
Q. Datc ApplicantBUILDING•
} N N01 ICE TO APPLICANT': If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
F Z emption,you should become subject to the Worken'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
<.0 such Provisions or this permit shall be deem00
ed revoked. AIR HANDLING UNIT(TO 10pC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is u cOnstruetkno 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 Nam
HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lenders Address ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) . 4.00
in(notation is correct. I agree to comply with all city and county PLUMBING
; u ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U3 6.00
hereby aulhorizu representatives of this city to enter upon [he' BOILER-COMP IDVof 100,000 BTU)SEE FEE MECHANICAL
above-mentioned property for inspection purposes. -
kayin
gree to save, indemnify sad keep harmless the City of MISC.- REFER TO ORD.
against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
y way Become against said City in conseuence of the this permit. MECH.CONT. LIC.NO. - MECH.
TOTAL TOTALof A plicant/Contractor .Date Y
OFFICE COPY