6267 Ai"PLICANT TO FILL IN INF TION WITHIN RED LINES - US POINT PEN ONLY
43U" PERMIT NUMBER -
DING LC!I NG PROJECT I DENTI F I '
aDaoING � APPLICATION & PERMIT (h�//� 7
AooRESS DJ� /� �I ,1�Er/Y'1✓(�71�. V 2 6 1�
J /`flfi I.IILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER' _
NAME PLAN CHECK VALIDATION
d JFt' „ OTY: ELECTRIC PERMIT FEE
PHONE
70 1J`
CONTRACTOR s_. -- OUTLETS-SWITCHES-RECEP 5.00/1.00 . 30S
LIGHTING FIXTURES 5.00/1.00 �•= /��e°
CONTRACTORS -
ADDR s APPLIANCES-RESIDENTIAL 4.00 S -
1�1 /n" ..
SJ J�PROrvE D PANELS 5.00 DATE OF APPLICATION
AORRCRITECT SIGNS - 6.00 PLAN CHEEZ7 P.C.NO.
ENGINEER
LIC,NO, SIGNS TRANS. 3.00NFICH -
A OGRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
ADDRESS MOTORS - SEE FEE SEH.
ADDRESS
SERVICE CHANGE 10.00 ?4_
oo LICENSED CONTRACTORS DECLARATION rSuwI hereby affirm that I am licensed under provisions of Chapter 9 ATE
(almmennng with Sec inn 7000)of Division 3 of the Rusinesspnd - BLOG. ELECT. PLG. MECH.
r N_m ,ofessi.NS Co d y license is in fall for of 4`1-V I
z 0 Ri! icense ss tic.Number '�
Z ta Uate 'Contractor -
¢ m a OWNER-BUILDER DECLARATION- - BUILDING PE MIT
K 0 u, INFORMATION,
K
°; LL w 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER,TO ORD - °t
or LL o a Law for the following reason.(Sec.7031.5;Business and Professions PERMIT ISSUANCE vheunnON S/FT.
Code:Any city orcounty which requires a Permit to construct,alter; - '6.00 L
m ELEC.CONTR. LIC.NO. h .A �' t'V
¢ rc¢ o improve,demolish,orrepair any structure:prior to its issuance,also ELEC, n
a wo u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
m he is licensed'pursuant to the,provisions of the Contractor's License ,
t z i Law(Chapter 9(commencink with Section 1000)of Division 3 of the -�p -
¢ Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEEtl t A �nr+IflD
¢ r m the basis for the alleged exemption.Any violation of Section7031.5 'STORIES TYPE CONSTR.
by any applicant for a permitsubjects the applicant toa civil penalty ALTER-DRAIN (EA.14.00
of not more than five huudred dollars(5500).): - `
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 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. 4:00 1 1 `
- 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 50.FT.FLOOR AREA TOTAL ACREAGE
himseB'or t hrough bis own employees,provided that such improve-
me GAS-EA.SVSTEM-11NC.40UTLETS'4.00
IMFmems are'not Intended or offered for sale.If,however,the building -
or improvement is sold within one year.of Completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 - BUILDING USE
builder will have the burden of proving that he did not build or am- RES IND CON .PB Omer
Prove 1,as owner
of the P INDUSTRIAL WASTE INTER. 20.00 ❑' ❑ ❑ ❑
❑ 1,as Owner of the property,am exclusively contracting with
licensed contractors to construcl the project(Sec. 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 or property who builds or improves thereat and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ Iamexemptlmder Sec. ,B.&P.C.forthis
reason WATER HEATER W/VENT 4.00
Owner Date WATER SYSTEM - 4.00 ACC.DATE ACC.FILE NO..
£. .
WORKERS'COMPENSATION DECLARATION WATER TR EATING EOUIP.� 4.00
I hereby affirm that I have a cer it f e at to sel Gimaim,
or a certificate of Workers'Compo 1 ace,Or a certified ZONING ENG.SITE NO. '
copy thereof fSec.3 00,h b.CJ a10 64"
Policy No.ergo _Co ny
O ' ❑ 'Cetined'C yish eby fu nishI$d. FIRE SPRINK ENERGYTz4
z Z ❑ Certifie op filed with.(he ty,inspection division.
O MISC.- REFER TO'ORD.
APplicam[ Y ❑ N Y ❑ N❑
CC T - I � ' - PERMIT ISSUANCE
LU Cli : COM: P COMPENSATION
I FROM WORKERS' 6.00 FLOOD ZONE A.L.u.c. 1.
-W � � '' :' COMPfiNSAT10N INSURANCE PLG.CONTR. LIC.NO. PLG.
2 0 ('Chis section need not he completed if the permit Is for one TOTAL Y❑ N❑ Y ❑ N❑
Z hundred dollars IS 100)or less.) -
. U O' 1 certify that in tie performance of the work for which this per- OTV MECHANICAL PERMIT FEE FEE SUMMARY
LL.P unt'is issued,I shall not employ any person in any manner so as to
O w became subject to Workers'Compensation Laws of California.
Q. DateApplicant ALTER OR ADD TO'MECH. 4.00 - BUILDING
} W NOTICF.TO APPLICANT: If,after making this Certificate of Ex-
i... Z" emplion,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
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=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE 02 ,
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 - HEATI NG UN IT ER 100,000 B.T.U.17.50
Lender's Address .ELECTRIC
I certify that'I have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
inl'onnat ion is correct.1 agree to comply with all city and county PLUMBING
- rdinances and state laws relating to building construction,and BOILER
-OON1P 13 H.P.or 100,000 B.T.U.) 4.00
.je v authorize representatives of This city to enter upon the BOI LER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes:
4� A
indemnifyand keep harmless the City of MISC.- - REFER TO ORD.
Cu [s,costs'and expenses which CONST.TAX
mago t sat City in nsequence of the PERMIT ISSUANCE 3.00 coTME .CONT. LIC.NO. MECH.0'� g TOTALTOTAL .iontractor Dale
1'
OFFICE COPY