2216 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL. POINT PEN ONLY
PERMITNU 16
BUILDING PROJECT 1 DENTI F[CATION !
•
BUILDING APPLICATION & PERMIT
ADDRESS
�; BUILDING- ELECTRICAL- PLUMBING-MECHANICAL
\ OWNER'S - A. - PLAN CHECK VALIDATION
"AME gl,'r dri "•sL ELECTRIC PERMIT FEE.
�u �7G/
P.
CONTPACTDR'6 1} OUTLETS•SWITCHE - 5.00/1.00
N E
uc.No LIGHTING FI OI7.00
rpop"qg%rgyR/�ag�SCTOR's gy/{'� APPLIANCES
ESID N A 4.00
n IIVACTi. Fa� PONEq�T��/ PANELS 5•00 DATE OF APPLICATION
APCN ITECT SIGNS , g,qq PLAN CHECK FEE P.C.NO.
OR
ENGINEER 3.00
UC.No. SIGNS TRANS.
ARCH.OR ENG. 5.00 PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT
ZIP EMP.METER OR POLE INS. 15.00
APPLICANT'S MOTORS SEE FEE SCH.
ADORES$
SERVICE CHANGE 10.00
L
Woo LICENSED CONTRACTORS DECLARATION
FU u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
I" (commencing with Section 7000)of Division 3 o the Busin ss a BLDG. ELECT. PLG. MECH.
0 4 z Professions C e, itLO is in full f k ' ❑ 1110❑
O 0 - Professions
LOC.Number V
w t W Date Contractor _ -- BUILDING PERMIT*h !>,i
a w OWNER-BUILDER DEC R ION REFER TO ORD �' ' INFORMATION
3 o u I hereby affirm that I am exempt from the Contractor's License MISC.- VALUATION $/FT.
LLOa Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
w 0 J Code:Any city or county which requimsa permit to construct,alter,
a: < C improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELE
y o W requires the applicant for such permit to file a signed statement that TOTAC.
L PERMIT TO
w$ he is licensed pursuant to the provisions of the Contractor's License
siry Law(Chepter 9(commencing with Section 7000)of Division 3 of the - F' k • 'r. 133x'.'.^- `9" + U- >[(.�'I--S1;C11Ve�L
a V's PLUMBING P.ERMITc FEE•�� / "
Business end Professions Code)or that he is exempt therefrom end QTY ST.+.rs- 6, d
¢ _ � the basis for the alleged exemption.Any violation ofsiction 7031.5 C:-mss is" rw , - -1?,vfy- 3.'-•ss�,„-,., ,,e P. }'"«;- STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(5500).):
❑ 1,as owner of the property,or my employees with wages as IBACK FLOW PROTECT.DEVICE 2.00 OCC.GROUPRES.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
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 SD.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM•1 INCA OUTLETS 4.00
ments are not intended or offered for side.If,however,the building
or improvement is sold within one year of completion,the owner- GAS•EA.SYSTEM-OVER 4 IEA) 100 BUILDING USE
-3
a builder will have the burden of proving that he did not build or int . . RES IND CON PB Other
prove for purpose of Sale.). INDUSTRIAL WASTE INTER. 20.00
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct 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 of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractod s)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
reason
Date Owner WATER SYSTEM 4.00 TLC_ ACC.FILE NO.
WORKERS'CONIPENSATION DECLARATION WATER TREATING EQUIP, 4.00
1 hereby affirm that I have a certificate of consent m self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab,". 6L �l/U 6h5xli
Policy No. Company
Q ❑ Certlf d Ishereby Ornish d. FIRE SPRINK ENERGY T-24
Z Z Jf Certifi SAMI with the city inspection division.
O MISC.- REFER TO ORD. y E) No y ❑ NN[]pPlicant
~ tnPERMIT ISSUANCv E 6.00 FLOODZONE A.L.U.C.
CERT KATE OF EXEMPTION FROM WORKERS'
U.11 _ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y N[]1 0 fThs idn need not be completed if the permit is for one TOTAL ❑ N❑
Z hundred dollars IS 100)or less.)
U O I certify That in the performance of the work for which this per, -L FEE SUMMARY;• iy!.L..
CITY."' - MECHANICAL'PERMIT.-:' 'FEE -
LL I- mit is issued.I shall not employ any person in any manner so as to „
U become subject to the Workers'Compensation Laws of California. - [5-e'
O w Date-Applicant BUILDING lU
aALTER OR ADD TO MECH. 4.00
} N NOTICE TO APPLICANT: If,after making this Certificate sa Ex
F. ? emvision you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK , 3Z
such provisions
io the Labor Code, you must forthwith comply with FEE (s° -
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO t0,00DGF.M) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IO,000C.F.M.) 5.00 SEISMIC FEE s3�
I hereby afDrm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the 3097.performance of the work for which This permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
Lender's Name HEATING UNIT IO VER 100,000 B.T.U.)7.50 ELECTRIC
Lenders Address
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
information n cStale l I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILFJR-LYNvIP 13 H.P.or 100,0008.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to ve, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cup tlino against hililies,judgments, costs and expenses which CONST.TAX
may in any w...pppJp//�r true against said City in consequence of the PERMIT ISSUANCE 3.00
gra n flhii�je MECH.CONT. LIC.NO. MECH. ;
�J�� TOTAL .TOTAL //-700
Sign ureof Applicant/Contractor Datel '
OFFICE COPY