16158 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
�UI LDI NG PROJECT I DENTI FICATION -PERMIT NUMBER }
BUILDING APPLICATION & PERMIT 1615 8
AOOREss
HI BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNEN'S PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
.TEFF n1RGNE 255-*7
CONTRACTOR'S
NAME OUTLETS-SWITCHES-RECEP 10,00!1,00
LIC.No, LIGHTING FIXTURES 10,00/1.00
CONCDNTRAcroRs•
ADDT AC - PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT - _ PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.Q NO.
ENGINEER
LIC.No, ISIGNS TRANS. 3.00
AOOReSS ENG SPECIAL CIRCUIT 5,00 -PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SEH.
SERVICE CHANGE 20.00 /SCJ yU
woo LICENSED CONTRACTORS DECLARATION /00
th
a i w I hereby affimt at I am licensed underpowisimhs of Chapte,9 l7 ISSUANCE DATE
y Q vi !commencing with Section 7000)of Division 3 of the Businessantl xB EWLI�ECT. PLG. MECH.
r., n z Professions Code,and my license is in fill]force and efoct. �J . ❑ 11o i L W License Class Lic.Number
L Datc Contractor -
ery s, ' 0 BUILDING PERMIT
c o u U OWNER-IIUILDIiR DECLARA'T'ION INFORMATION
X ; H I hereby affirm that I am exempt from the Contractor's License MISC. REFER TO ORD
c o In Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city orcounty which requires a pennit to construct,alter, � a(f-(}
¢ a,¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO, ELEC. /
ca
o ¢ requires the applicant for such permit to flea signed slalmnent that TOTAL
a w m ac he is licensed pursuant to the provisions of Elio Contractor's License PERMIT O
r z r Law(Chapter 9(commencing wit h Section 7000)of Divisiun3 ofthe ?If/
Q
4 o Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ r-m the basis for the alleged exemption Any violation of Section]031.5' STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
DO not more than five hundred dollars(8500).):
❑ I,as owner of the property,of my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 Oce.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for salt (See 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,CON D. '5.00
Code:The Contractor's License Law docs nor apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PE R TRAP - 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
mems l'or are of ante his own employees,provided that such improve.oroffered If,however,the the owner. GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or!der Will
is sold within one year of lie did iot the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2,00
builder will have the bunion of pmving that hu did not build or in,. - BUILDING USE
prove for purpose of sale.). RES INP CON PB OtherINDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
❑ d as owner of the property,tile
exclusively contracting with
licensed contractorsto he
ntrator project,La 7044,Business LAWN SPRINKLERS- 1' INC5 V.B. 6.00 ASSESSOR6PARCEL NO.
and n owner of Cole:The Contractor's i 1-kerne law does not apply
to contracts
owner of property who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 _
the Contsctor'shcenjeets Lwithu contractor(s)licensed pursuant(I) SEWER-SANITARY-STORM EA.200tt/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lamexe h t oder Se . ,B.&P.C.tnr this WATER HEATER W/VENT 6.00
ollosal caner Dare WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. ,
K FRS'COMPF.NSATION DECLARA'T'ION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofcomamt to self-insure. ZONING ENG.SITE N0.
or a certificate of Workers Compensation Insurance,or a certified
copy thereof(Sec.3800,1-.B.C.).
Policy Nn. Comp:my
O O Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant V❑ N❑ Y ❑ N❑
~ rn
LU - CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 - FLOOD ZONE A.L.U.G.
W > CMPEOIiNSATION ION INSURANCE
URANCE PLG.CONTR. LOC.NO. PLG.
1 0 ('Chis section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
Z) Z hundred dollars IS 100)or less.)
L) O 1 certify that in the performance of the work for which this per. CITY. MECHANICAL PERMIT FEE FEE SUMMARY
W F mit is issued,I shall nor mrlploy any person in any runner so as to
O w become subject to the Workers'Compensation Laws of California.
Dam A licant BUILDING (
} W NOTICE '10 APPLICANT:If,after making This Ccrtifichm of Ex- "ALTER OR ADD TO MECH. 5.00 �v _
FZ coalition,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revokecl. AIR HANDLING UNIT ITO 1Q000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.FM.) 6.00 SEISMIC FEE �f7J
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 Addy HEATING UNIT(OVER 100,000 B.T.U.)_ Lender's Address ELECTRIC
I certify that l have,cad this applieotion and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county BOILER-CUMPI3 H.P,or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to rover upon the
above-memioned property for inspection purposes. BOILER-COMP 10'vor 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC,- REFER TO ORD.
upertimo against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
sy-in any way accrue a ainst sa' City in consequence of the rRatio 1 i mit MECH.CONT. LIC.NO. MECH.
/$ TOTAL TOTAL �5--1�
i8 Applican ontractor Date -
OFFICE COPY