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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES.- USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING
PERMIT NUMBER
O Q
s 0
0�'q
BUILDING
aooREs
a
OWNERS
NAME I/ prrtsoN
YE PHONE ?
DTV. ELECTRIC PERMIT FEE
-
PLAN
�VjIG_. I'V
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NaMEH CTT RS IC47S;r 5�1�.
UTLETS- SWITCHES -RECEP 10.00/1.00 Ir
LIGHTING FIXTURES 10.0017.00
uc. No,
�N
CdiaTl'c-�L '" 66DO
ADDRESS
APPLIANCES PPLIANCES- RESIDENTIAL - .4.00 2.�'
PANELS - 10,00
DATE OF APPLICATION
A CHITECT
OR
ENGINEER
LID. NO.
PANELS (OVER 200 AMP) .20.00
C Lft N
1" IN C
I
nPLAN CHECK FEEWIM
SIGNS TRANS. 3.00
ADDRESS ENG.
SPECIAL CIRCUIT 5,00
PE M VALID
TEMP. METER OR POLE INS. 20.00
ZIP
APPLICANTS
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
Q .}
LICENSED CONTRACTORS DECLARATION
-
I hereby affirm that 1 um licensed under Pr0Vltl0ns of ChaPter 9
(commencing witl#yction 7000) of Division 3 of the Business and
Professions Code my license is in full fo t cSt
ISSUANCE GATE
BLDG. ELECT. PLG. •M_ ECH.,
License Cla LNumber
Date Cic.ontmclor
/IYJ^(ll(
BUILDING PERMIT
INFORMATION
OWNER-BUILDFR D'
I hereby affirm that I an exempt from the Contractor's pr License
Law for the following reason. (Sec. 703 1.5, Business and Professions
Code: Any city or county which requires a permit to construct, ulteq
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant fOr SUCK Permit to file a signed statement that
he is licensed Parttant to the provisions of the Contractor's License
Law (Chapter 9 (commencing with Section 7000)0f Division 3 of the
Business and Pnil'eNuons Code) or that he is exempt therefrom and
MISC.— FERTOORD
PERMIT IS AA:BO
VAL TION FT.
ELEC.CDNTR. - UY049F' ELEC.��
TOTAL E (}l
QTY. PLUMBING PERMITt4.00
PER MIT TO
N -1f l%0,
F'
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant loll civil penalty
of not more than five hundred dollars (5500).):
STORIES
TYPE CONSTR.
ALTER-DRAIN&VENT-WATER (EA.)
❑ I, as owner of the properly, or my employees with wages as
their sole comp-nsation, will do the work, and the structure is notintended
BACK FLOW PROTECT. DEVICE
OCC. GROUP
REB. UNITS
DRAINS -FLOOR, ROOF, AR EA, COND.Code:
Or offered for sale (Sec. 7044. Business :end Professions
The Contractor's License Law does not apply to an owner of
FIXTURES - PER TRAP
GAS-EA.SYSTEM-11NC.40UTLETS 6.00
property who builds of improves thereon, and who does such work
himself or through his own employees, provided that such improve-
mentsare not intended oroltend for sale. If, however, the building
SO. FT. FLOOR AREA
ys L-�.Z-V.
TOTAL ACREAGE
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving shat It did not build or int-
prove for purpose of sale.).
13.
I, as owner of the property, at exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
B UI USE
RES IND CON PB Omer
1:1 El El ❑ El
INDUSTRIAL WASTE INTER. 3000
contractors to Construct the project (Sec. 7044, Business
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- 1 INC 5 V.B. 8.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
con tenets for such projects with u contractor(s) licensed pursuant to
the a
Conlctor's Liceose•Ww.
❑ am exempt under Sec.—, B.&P.C. for this
reason
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
WORK ERS'COMPENSAT1ON DECLARATION
WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self -insure,
-
ZONING
ENG. SITE NO.
or a certificate of Workers' Compensation Interstice, or a certified
copy thereof (Sec. 3600, Lah.C.). .k�q /((no D to
P o. Company_ /-'1 C
i—
Ccrlilied copy is hereby famished'
❑ ertifieJ copy is filed with the city inspection division.
Applicant
MISC.- REFER TO ORD.
FIRE SPRINK
Y ❑ N ❑
ENERGY T-24
Y ❑ N[—]CFRTIFICAT170P
EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE
section need not be completed if the permit is for one
PERMIT ISSUANCE .i 0;00' dv
FLOOD ZONE
Y ❑ N ❑
A.L.U.C.
Y ❑ NE]
PLC, CONTR. LIC. NO,
TEG
OTAL
hundred dollars 1$ 100) or less)
hundred
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so as to
QTY MECHANICAL PERMIT FEE
E SUMMA
become subject to the Workers' Compensal ion Laws of California.
ALTER OR ADD TO MECH. 5.00
Dat° Applicant
ILDING
1
NOl'ICE TO APPLICANT: If, after making this Certificate Of Ex-
APPLIANCE 5.00
_
AIR HANDLING UNIT ITO iW WC.r.M-) 4,00
RC- E$K
Ear
emption, you slmuld become subject In the Workers' Compensation
provisions of the Labor Cade, you must forthwith Comply with
such provisions or this pennit shall be deemed rev(dked.
CONSTRUCTION LENDING AGENCY
AIR HANDLING UNIT (OVER 10=C.F.M.) 6.00
SEISMIC FEE It
EXHAUST HOOD (WITH DUCT) 5.00
I hereby affirm Ihut'there is a construction lending agency for
the performance of the work for which this perinit is Issued (See,.
3097, Civ.CA
MICROFILM
HEATING UNIT (TO 100,000 B.T.U'.) 8.00
Lender's Name
Lender's Address
HEATING UNIT (OVER 100,000 B.T.U.M50
ELECTRIC 3s.W
. I certify that l have read this application and state that the above
VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county
ordinances and state laws relating to building construction, and
BOILER- COMP(3 H.P. or 100,000 B.T.U.) 6.00
�^ p,
PLUMBING 20 w
hereby SIR
hereby enthorite representatives this city to enter upon the
d property representatives
or inspection ofdu purposes.
BOI LER-COMP boiler 100,000 BTU) SEE FEE SCH. -
MECHANICAL
`
(We) ago o save, indemnity and keep harmless the City of
MISC. - - - REFER TO ORD.
Day in ceme against saiA consequence the
upertino st liabilities, judgmenu';4
CONST. TAX
PERMIT ISSUANCE. 10 Cl0
rami ortil.
CH. CONT. LIC. NO.
MECH.
Applicant Con
,TOTAy
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A
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES.- USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING
PERMIT NUMBER
O Q
s 0
0�'q
BUILDING
aooREs
a
OWNERS
NAME I/ prrtsoN
YE PHONE ?
DTV. ELECTRIC PERMIT FEE
-
PLAN
�VjIG_. I'V
Q I
V ' 1E
��
NaMEH CTT RS IC47S;r 5�1�.
UTLETS- SWITCHES -RECEP 10.00/1.00 Ir
LIGHTING FIXTURES 10.0017.00
uc. No,
�N
CdiaTl'c-�L '" 66DO
ADDRESS
APPLIANCES PPLIANCES- RESIDENTIAL - .4.00 2.�'
PANELS - 10,00
DATE OF APPLICATION
A CHITECT
OR
ENGINEER
LID. NO.
PANELS (OVER 200 AMP) .20.00
C Lft N
1" IN C
I
nPLAN CHECK FEEWIM
SIGNS TRANS. 3.00
ADDRESS ENG.
SPECIAL CIRCUIT 5,00
PE M VALID
TEMP. METER OR POLE INS. 20.00
ZIP
APPLICANTS
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
Q .}
LICENSED CONTRACTORS DECLARATION
-
I hereby affirm that 1 um licensed under Pr0Vltl0ns of ChaPter 9
(commencing witl#yction 7000) of Division 3 of the Business and
Professions Code my license is in full fo t cSt
ISSUANCE GATE
BLDG. ELECT. PLG. •M_ ECH.,
License Cla LNumber
Date Cic.ontmclor
/IYJ^(ll(
BUILDING PERMIT
INFORMATION
OWNER-BUILDFR D'
I hereby affirm that I an exempt from the Contractor's pr License
Law for the following reason. (Sec. 703 1.5, Business and Professions
Code: Any city or county which requires a permit to construct, ulteq
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant fOr SUCK Permit to file a signed statement that
he is licensed Parttant to the provisions of the Contractor's License
Law (Chapter 9 (commencing with Section 7000)0f Division 3 of the
Business and Pnil'eNuons Code) or that he is exempt therefrom and
MISC.— FERTOORD
PERMIT IS AA:BO
VAL TION FT.
ELEC.CDNTR. - UY049F' ELEC.��
TOTAL E (}l
QTY. PLUMBING PERMITt4.00
PER MIT TO
N -1f l%0,
F'
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant loll civil penalty
of not more than five hundred dollars (5500).):
STORIES
TYPE CONSTR.
ALTER-DRAIN&VENT-WATER (EA.)
❑ I, as owner of the properly, or my employees with wages as
their sole comp-nsation, will do the work, and the structure is notintended
BACK FLOW PROTECT. DEVICE
OCC. GROUP
REB. UNITS
DRAINS -FLOOR, ROOF, AR EA, COND.Code:
Or offered for sale (Sec. 7044. Business :end Professions
The Contractor's License Law does not apply to an owner of
FIXTURES - PER TRAP
GAS-EA.SYSTEM-11NC.40UTLETS 6.00
property who builds of improves thereon, and who does such work
himself or through his own employees, provided that such improve-
mentsare not intended oroltend for sale. If, however, the building
SO. FT. FLOOR AREA
ys L-�.Z-V.
TOTAL ACREAGE
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving shat It did not build or int-
prove for purpose of sale.).
13.
I, as owner of the property, at exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
B UI USE
RES IND CON PB Omer
1:1 El El ❑ El
INDUSTRIAL WASTE INTER. 3000
contractors to Construct the project (Sec. 7044, Business
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- 1 INC 5 V.B. 8.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
con tenets for such projects with u contractor(s) licensed pursuant to
the a
Conlctor's Liceose•Ww.
❑ am exempt under Sec.—, B.&P.C. for this
reason
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
WORK ERS'COMPENSAT1ON DECLARATION
WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self -insure,
-
ZONING
ENG. SITE NO.
or a certificate of Workers' Compensation Interstice, or a certified
copy thereof (Sec. 3600, Lah.C.). .k�q /((no D to
P o. Company_ /-'1 C
i—
Ccrlilied copy is hereby famished'
❑ ertifieJ copy is filed with the city inspection division.
Applicant
MISC.- REFER TO ORD.
FIRE SPRINK
Y ❑ N ❑
ENERGY T-24
Y ❑ N[—]CFRTIFICAT170P
EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE
section need not be completed if the permit is for one
PERMIT ISSUANCE .i 0;00' dv
FLOOD ZONE
Y ❑ N ❑
A.L.U.C.
Y ❑ NE]
PLC, CONTR. LIC. NO,
TEG
OTAL
hundred dollars 1$ 100) or less)
hundred
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so as to
QTY MECHANICAL PERMIT FEE
E SUMMA
become subject to the Workers' Compensal ion Laws of California.
ALTER OR ADD TO MECH. 5.00
Dat° Applicant
ILDING
1
NOl'ICE TO APPLICANT: If, after making this Certificate Of Ex-
APPLIANCE 5.00
_
AIR HANDLING UNIT ITO iW WC.r.M-) 4,00
RC- E$K
Ear
emption, you slmuld become subject In the Workers' Compensation
provisions of the Labor Cade, you must forthwith Comply with
such provisions or this pennit shall be deemed rev(dked.
CONSTRUCTION LENDING AGENCY
AIR HANDLING UNIT (OVER 10=C.F.M.) 6.00
SEISMIC FEE It
EXHAUST HOOD (WITH DUCT) 5.00
I hereby affirm Ihut'there is a construction lending agency for
the performance of the work for which this perinit is Issued (See,.
3097, Civ.CA
MICROFILM
HEATING UNIT (TO 100,000 B.T.U'.) 8.00
Lender's Name
Lender's Address
HEATING UNIT (OVER 100,000 B.T.U.M50
ELECTRIC 3s.W
. I certify that l have read this application and state that the above
VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county
ordinances and state laws relating to building construction, and
BOILER- COMP(3 H.P. or 100,000 B.T.U.) 6.00
�^ p,
PLUMBING 20 w
hereby SIR
hereby enthorite representatives this city to enter upon the
d property representatives
or inspection ofdu purposes.
BOI LER-COMP boiler 100,000 BTU) SEE FEE SCH. -
MECHANICAL
`
(We) ago o save, indemnity and keep harmless the City of
MISC. - - - REFER TO ORD.
Day in ceme against saiA consequence the
upertino st liabilities, judgmenu';4
CONST. TAX
PERMIT ISSUANCE. 10 Cl0
rami ortil.
CH. CONT. LIC. NO.
MECH.
Applicant Con
,TOTAy
'
l
♦
TOTAL r_eo
v A+�