6619 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
gN,Ln,Nr, APPLICATION & PERMIT 6619
400R 555
�/,Q- / BµµU��.��I��LDING -ELECTRICAL-PLUMBING-MECHANICAL
NAME
S yaY3 ryr}"f*}.e f ffi'P a ��l' 'w"9 x/�kf� - 17 ryr�'y^yam. PLAN CHECK VALIDATION
d ELECTRIC HERMIT,Kr,)s;icy "" EE�4,/`
`NONE x J a.,lip'ka
CONTRACTOR'S
1 N - UTLETS-SWITCHES-RECEP 5.00/1.00
AME
/ � L�No, LIGHTING FIXTURES 5.00/1.00
-r.. CONTRACTOIR _ PPLIANCES-RESIDENTIAL 4,00
! 1J 0PRONE � Vf,.'fy PANELS 5.00 DATE OF APPLICATION
a HITECiSIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER D I �
itl //t
11. NO. 1 (/ -n SIGNS TRANS. 3.00
ARC.,OR ErvG. PERMIT VALIDATION
AooR / SPECIAL CIRCUIT 5.00
i i
1/ ✓vV I ��r ) ZIP rrEMP.METER OR POLE INS. 15.00
4P. s
ACa`EsMOTORS SEE FEE SCH.
ORE ss s
SERVICE CHANGE 10.00 97�-
J�Y�
Woo LICENSED CONTRACTORS DECLARATION
¢ U u I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
Z H (co...aTo ing with Section 7000)0(Division 3 of the Business BLDG. ELECT. PLG. MECH.
I- o z Professions Cod•a license is in full for cl.
O i=w iccny Cl ss Z Lie.Numher 8
m� at{vMg_ Contractor
a r s ICDI OPE M_IT "
¢ ¢w¢ OWNF,R-BUILDER DECLARATION
w ;` r I hereby a(firn that I am exempt from the Contractor's License MISC.- REFER TO ORDPAI
.. o a Law for the following reason,ISec.7031.5,Business and Professions PERMIT ISSUANCE VALUATION ;/FT.
Code:Any city or county which requires permit to construct.alter, 6'�
¢ ¢ e Q improve,demolish.or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO, ELEC. C
O m requires the applicant for such permit to file a signed statement that TOTAL L O PERMIT TO
whe is licensed pursuant to the provisions of the Contractor's License
H i Law(Chapter 9(commencing with Section 7000)o(Division 3 ofthe a`14'x 1T'4'lh �Rth° 4 ti.+i�yw{ ,er,��N �. �C•LlL(.-r
�_ 'r Business and Professions Code)or that Ise is exempt therefrom and STT: r' .PLUMEIN<i R I T,.' t q u
o lf�.Y..• .Y�+i,' STORIES TYPE CONSTR.
¢ H the basis for the alleged exemption.Any violation of Section 7031 5 ,fi4,r IM q,._ 41w
n ; m by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(5500).1:
❑ I.as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their Mode compensation,will do the work,and the structure is not
intended Or offered for sale (Sec. 7144, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
• 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 4.00 SO.FT,FLOOR AREA TOTAL ACREAGE
himself Or through his own employees.provided that such improve- GAS-EA,SVSTEM-1 4.00
meats are not intended or offered for sale.IL however,the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did mol build or im-
prove for purpose ofsale.l. INDUSTRIAL WASTE INTER. RES IND CON PB Omer
❑ I,as owner of the property,am exclusively contracting with 20.00 ❑ O 0 ❑
licensed contractors to construct the project tSec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 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
umtracis for such projects with a contractosts)licensed pursuant to
the Contractor's License Law. - SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 4.00
rvson
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPF-NSATION DECLARATION WATER TREATING EQUIP. 4.00
1 1 hereby affirm that I have a certificate u(consent to self-insure, ZONING ENO.SITE NO.
'/ or a ct,niftcute of he ers'Compensation Insurance,or a certified
copy there 3$ La b,000��'). n
Policy No 'C inIT /
Q ,y �I Certit top h¢Te Vl urnished. FIRESPRINK ENERGY R29
z 2 ❑ Certili is 0 s he city inspection division.
O MISC.- REFER TO ORD. ❑ � ❑
Applicant V N V N
Cr y CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO, PLG.
1 y N� O NE]
(This section need not be completed if the permit is for one TOTAL
Z hundred dollars(SIOO)or less.) as;,; T ,4 r-'�'�41 - i'r'4ts n §'r`ita••' '� '' brat
V O 1 certify that in the performance of the work for which this per a q. > s �• 3''I,jP_EE EUMMARV'`•d$ rxjxl
IL H mit is issued I shall not employ any person in any manner so as to ,nTysY„,LL �* MECHANICAILPERMIT q ,P,EE ' - >a
O W become subject to the Workers'Compensation Laws of California. ;' :k't4 '•;•' P •;•e'<' v e,;'^ h _ _st,
C. Date Appl"°m ALTER OR ADD TO MECH. 4.00 BUILDING .((�
} N NO'T'ICE TO APPLICANT: If,after making this Certificate of Ex.
H Z emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK 3 4
provisions of the Labor Code, you must forthwith comply with FEE �
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=12-F.M) 3.00
C'ONS1 RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10000.EM.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Leader's Address ELECTRIC
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
.information is correct I agree to comply with all city and county PLUMBING
.oNinences and stale laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
I
Te rep esen lalives of this city to enter upon the BOILER-COMP(Over 100,0008TU)SEE FEE SCH. MECHANICAL
d pr erty spection purposes.o e, harmless the City of MISC.- REFER TO ORD.
s, sabilities,judgmentscosts and expenses which pERM1T ISSUANCE 3.00CONST.TAX
icerof the eessMECH
er ( MECH.CONT. LIC.NO. TOTAL It'wasiY� �x't `M 74
igneture of APPlicuntlCon[raclor Dat 0"r;,k,�;y,' "w^5:'1 ;ri
OFFICE COPY