3687APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICA
APPLICATION & PET
BUILDING — ELECTRICAL— PLUMBING — MECHANICAL
PERMIT NUMBER
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PLAN CHECK VALIDATION
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AWrvER's
NAME o
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PHONE
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OTY. ELECTRIC PERMIT FEE "
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LONTR ALTO 'S
NAME -
' uc. NG.
OUTLETS -SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
CONTRACTORS
ADDRESS
I APPLIANCES - RESIDENTIAL '4.00
PANELS 5.00
PHONE
DATE OF APPLICATION
ARCHITECTSIGNS
OR
ENGINEER
LID. NO. ''
- - 6.00
PLAN CHECK FEE
'
P.C. NO,
SIGNS TRANS. - 3.00
AARCH. OR DDRESS ENG, - -
SPECIALCIRCUIT 00
PERMIT VALIDATION
EMP. METER OR POLE INS. 0
ZIP
1'
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ADDRESS
ADDRESS
MOTORS EE FEES H.
SERVICE CHANGE 10. '
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YSU
LICENSED CONTRACTORS DECLARATION
hereby affirm that 1 am licensed under provisions of Chapter 9
(commencing with Section 7000)'6f Division 3 of the Br91ne95 and
Professions Code, and my license is in full force and effect
License Class Lia Number
01� of
°N
BLDG.
ELECT. PLG. MECH.
Date Contract.[
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from [he Contractor', License
Law for the following reason. (Sec. 7031.5, Businessand Professions
requires ore permit o itsconstruct,isace, also
Code: preu, y city or coonty whiny structure,
improve, demolish, or repair any sticture, e a prior to its iateme t that
requires the applicant for 9uC11 Derail to file a 91g11eIl statement Ila'
he Is licensed pursuant to file provisions of the Contractor's License
Law (Chapter 9 (commencing with Section 7000) of -Division 3 Artie
Business and Professions Code) or that Ile is exempt therefrom and
BUILDING PERMIT
I ION
VA LUA
MISC. - REFER TO ORD
PERMIT ISSUANCE 6.00
-
ELEC. CONTR. LIC. N0.
ELEC. Owl
TOTAL
PERMIT TO
�LU�
DTV. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the basis for rhe alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (S500)J'.
�s '/s
J �C.
ALTER -DRAIN -WATER (EA.)q,00
❑ 1, as owner of the property, or my employees with wages as.
their sole compensation, will do the work, and the simulate is not
intended or offered for sale (Sec. 7044, Business and Professions
BACK FLOW PROTECT. DEVICE 2.00
DCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
Code: The Contractor's License Law does not apply to an owner of
,/`
FIXTURES - PER TRAP 4.00
sG. FT. FLooR AREA
TOTAL ACREAGE
properly who builds Or improves thereon, and who does such work
himself or through his own employees, provided tin[ such improve-
isarenotintendedoroffer.1 for Sale. If, however, till building
-
GAS-EA.SYSTEM-l1NC.40UTLETS 4.00
pro sed, ;cm is'sold within one year of completion, tine owner-
builder will have the,burden of proving that he did not build or air-
prove 11, as r`pose of tireJ.
❑ I, as owner of the property, am exclusively contracting with
GAS
GAS - EA. SYSTEM - A.) 1.00
BUILDING uGE.
IND CON PB Other' -
INDUSTRIAL WASTE INTER. 20.00
licensed contractor`s to construct the project (Sec.7044, Business
odd Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who
contracts for such projects with a contracm Ns) licensed pursuant to
the Contractor's License Law. - .
LAWN SPRIN KL 1 Ob 5.00.
LAWN SPR INKL S m OVER 5 (EA'.) ' _; 1,00
ASSESSORS PgacEt NO.
SEWER-SAssi Oft/8.00
TRACT NO.
PARCEL NO.
❑ tum xe funder Sec. ,B.&PTC Inn this
ase
WATER HEATER W/VENT - 4,00
DaleI Owner
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO.
WATER'TREATING EQUIP. 4.00
WORKERS'COMPENSATION DECLARATION -
I hereby infirm -that I have a cerlificate ula use"' to'elfHosure,
or a certificate of Workers' CAnlpensation Insurance, cr a certified
r
ZONING
ENG. SITE NO.
-
copy thereof
ereof (Sec 3800, Lab.C.).
Policy No. Company
-
FIRE SPA INK
Y ❑ IN
ENERGY T 24
- Y ❑ NCD
O Certified copy is hereby furnished.
❑- Certified copy is filed with the city inspection division.
Applicant
MISC. - - REFER TO ORD.
CERTIFICATE OF EXF MPTION FROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A. L,u U.C.
COMPENSATION INSURANCE
(T his section need not be completed if the permit is fur rare
PLG. CONTR. -LIC. NO.
-
PLG .
TOTAL
Y N
Y N
hundred dollars IS 100) or IYO
I certify that in the performance of the work for which this per-
mil is issued, I shall not employ any person in any manner so as to
GTY. MECHANICAL PERMIT FEE
- -
FEE SUMMARY
BUILDING
Tia Ov
become subject to the Workers' Comfor sation Laws of California.
Date Applicant
.-:
ALTER ORADD TO MECH. 4.00
NOTICE. 'f0 APPLICANT', If, after making this Certificate of Bx-
emption,'you should become subject to the Workers'Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be decried revoked.
APPLIANCE 4.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10,000 C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY
AIR HANDLING UNIT(OVER 10=C.EM.)5.00
SEISMIC FEE
I hereby affirm (hal there is o construction leading agency I'or
EXHAUST HOOD (WITH DUCT) - 2.00
the performance of the work for which this penint is issued (Sec.
3097,Civ.C.).
MICROFILM
HEATING UNIT IT B.T.U.) 4.00
Name
Lender's Address
HEATING UNIT (O ,000 B.T.U.)7,50
'ELECTRIC
VENTILATION FAN (S L 3.00 '
I certify that I have read this application and state that the above
inf;�rm flan iv correct. Lagree to comply with all city and cotmay
' arcus "id Sate laws relating to building construction, and
_'
PLUMBING• -
�� V.r
BOILER -COMP( O,000B.T.U.) 4.00
BOILER -COMP IOver 100, EE 6CH.
MECHANICAL
,y rize representatives of this city to enter upon the
-1uol'e-mentioned property for inspection purposes. _ '
(We) agree to Tve, indemn' 'and keep harmless the City of
Iahilities, dgme costs and expenses which
n ainst Ci[ in consequence of the
MISC.ORD.
CONST. TAX
-
PERMIT ISSUANCE 3.00 O
�countMECH.
wCupeTtino"
CONT. LIC. NO.
MECH.
TOTAL
TOTAL
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