15103 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON - - PERMIT NUMBER
X Soo DIN APPLICATION & PERMIT '
151 3
x145.0 /O JG�� 1 BUILDING-ELECTRICAL-PLUMBING-'MECHANICAL Ce- J 1
OWNER'S r�'r l't 4 - PLAN CHECK LIDATION
NAME QTY. ELECTRIC PERMIT FEE „n
�(
D. L'. I bertSCuPHDNa?S7- b'4 ' ✓
COME NTRACTORS
NAOFEE OUTLETS 10.00/1.00,
LIC.NO. ,�. LIGHTING FIXTURES ' 10.00/1.00
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4'.00
ADDR ESE
PHONE PANELS _ 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00
ENGINEER PLAN CH ECKP.C.NO.
OR
uc.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIALCIRCUIT •5.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT'S MOTORS SEE FEE SCH.ADDRESS
QyC/C
SERVICE CHANGE - '20.00
0 0 oF LICENSED CONTRACTORS DECLARATION 6
au , I hereby affirm that 1 am licenses] under pmvisiona Of Clm PteT 9 . ISSUANCE DATE
Z w (commencing with Section 7000)of Division 3 of the Nuslness and
BLOC.
vDD�i Professions Code,and my license is in full force and effect. rxvIt
ELECT. PLG. MECH.
D 0 w W License Class Lie.Number (.� ❑
Dale Contractor l�
Y f� BUILDING PERMIT
¢ m w ¢ OWNER-BUILDER DECLARATION INFORMATION
A o A MISC.- REFER ORD
w LL H 1 hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
F u o g Law for the following reason.(Sec.7031.5,lloroossand Professions PERMIT ISSUANCE _
M Code:Any city or county which requires a permit to construct,alter;
rc ¢¢ improve,demolish,or repair any structure,Prior to its issuance,also ELEC.CONTE. LIC.N0. ELEC.
O u requires the applicant for such permit to file a signed statement that TOTAL J PERMIT TO
n w m he is licensed pursuant to the provisions Of tle Contractor's License
r Z i
Law(Chapter 9(commereogwith Section 7000).f Division3ofthe �J 72-
- a Business and Professions Code)or that be is exempt therefrom and QTY. PLUMBING PERMIT FEE
ar Ihebusis forthealleged exemption.Any violation of Svcdon703L5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant penalty ALTER-DRAIN&VENT-WATER (EA.) SAO
of not more than five hundred dollars(SSOOLL 3
9-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 the structure is not
Intended or offered for sale(Sec. 7044, Business and Professions •DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractors 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 Si FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedor offered for sale.If,however,the building GAS-EA.SYSTEM-l1NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner GAS-EA.SYSTEM-OVER 4 IEA.) 2,00 BUILDING USE
builder will have lite burden of proving that he did not build or inr
prove for purpose of sale.). - INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ 1,as owner Of the properly,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-i INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and ProfcssionS Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon.Imal who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with it contractors)licensed pursuant to SEWER-SANITAR V-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I:un exempt under Sec. ,B.&I'.C.for this WATER HEATER W/VENT 6.00
reason
Own Date WATER SYSTEM 5.00
ACL.GATE ACO.FILE N0.
WORKERS'COI,IPFNSA'17ON DECLARATION . WATER TREATING EQUIP, 5.00
1 hereby affirm that I have a ce]IEcate of consent In self-insure, ZONING
or a certificate of Workers'Compensation Insurance,or u certified ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.). '
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Cerlified copy is Cited with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y ❑ N❑ Y ❑ No
CC~ rnPERMIT ISSUANCE -19:6.8Ml
1 CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ZONE A.LU.C.
LU COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.CL 0 (This section need not be completed if llte'permil is for one TOTAL Y❑ N❑ Y ❑ N❑.
=) Z hundred dollurs($100)or IISSL -
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any manner or as in _
U become subject to the Workers'Compensation Laws of California.
U w Date A licant BUILDING
pP - ' ALTER OR ADD TO MECH. 5.00 . O
} tail
NOTICE you
APPLICANT If,bjcr making this Cl.'rt ompv of
H Z enlptiion you should become subject m the Workers'Compensation APPLIANCE - 5.00 PLAN CHECK
provisions io the Labor Code, you mull forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000 C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY - AIR HANDLING UNIT(OVER IO=C F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction 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 Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
1 certify that 1 have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and slate 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 lo,enter upon the BOILER-COMP (Over 10Q000RTU)SEE'FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
aper ino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
tingofthisperl IT. MECH.CONT . LIC.NO. MECH.
elo. 3--It TOTAL TOTAL
nature of Applic t onlractor Date
OFFICE COPY '