14417 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
�
BUILDING
BUILDING PROJECT IDENTIFICATION FICATION /'- APPLICATION & PERMIT 1 441 7
Bm LOIN ` /G'
AD Rrss
IOC 5 - -A N. ✓ GF BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
AME CITY. ELECTRIC PERMIT FEE -1"7
.I/�l G/'))�' /`C`i/•PHONE � �O� /�/ ILP
CONTRACTons � UTLETS-SWITCHES-RECEP 10.00/1.00
A E
CONTRACTORS
'J ON uC.ND 3� LIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ODRESS �J �)
PHONE /� 'f/ PANELS 10.00 DATE OF APPLICATION
ENGINEECT ,r- /�3p"G G� PANELS (OVER 200 AMP( 28,08 PLAN CHECK FEE N.C.NO.
OR ✓✓ �V 33''
ENGINEER
LICNO J 2270 SIGNS TRANS. 3.00
. +
ARCH.OR CNG. >e_'. ISPECIAL CIRCUIT 5,00 PERMIT VALIDATION
NODR SS f ,1 ,11, p
6oe4;v/" rr'14Ei- ¢IP/�S EMP.METER OR POLE INS. 20.00 y'�,,
APPLICANT'S MOTORS SEE FEE SCH. PiuoiC
ADDRESS / �'
SERVICE CHANGE 20.00 6
,- 02 o O LICENSED CONI'ItACT'OKS DECL,112ATICIN V vJ
¢ u U I hereby ulfion that I all,licensed I eiE DATE
a z u. (commencing with Section 7000)of Division 3 of Ilm Bns�i(ne3�»and PLG. MECH.
wi Professions C.dc.i i yy licem,•is in lull torte ayd it I�j,�
, 0 N Licenu Chace_(_/ Lie.Numbe,_�jj/77r' ❑ ❑ ❑ ❑
a y 3 j QY,1NS? BUILDING PERMIT
¢ ¢ w a OWNFR-BUILDER DECLARA'[]ON INFORMATION
REFERTOORD
g H I hereby affirm that I um exempt from the Contractor's Lieelnc MISC.-
uOa Law for the following re mon.(See.7031.5,Bunn...and)'rulcs,iunz - PERMIT ISSUANCE 10.00 VALUATION
SIFT.
E - Code:Any city or county whichrequiresapannit loconstruc6aheq �,.�-0
j
¢ a Q improve,denulish,or repair any structure,prior to its C issuance,also CLECONTR. LIC.NO. ELEC. 3
a a 0 Q requires the applicant for such permit 1a file a,ignttl statement that TQ9 V✓OTAL PERMITTO
A,
m he is licensed pursuant to the provision,of the CnRramoi s License
rziLaw(Chapter'9fcomnhuming with Section 70001 of Division 3 of the
a Business.,,it Prol'essiuns Coda)or that he is exempt therellonl and CITY. PLUMBING PERMIT FEE
f i D
¢ H
the ball for the alleged eoRit uscioplion.Any vi plawa of Sadion malty STORIES TYPE CONSTR.
by any applicant l'orupcnre Subject,lheapplicunno.civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not mare wtic live lie prod.lullun 155001.1:
❑ Las owner of the will do t or my,and tics with a is Hot BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
inter sole r offered
fo,will(S the work,and 0m am<bol a not
intended or offered for sale (Seca 7094, not appl and Profession, DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code',The C build or License Law does not apply to an owner 1,
property who Hoods or inmrovn thereon,and who docs suds wok FIXTURES-PER TRAP 5.00 SO FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,Provided that such rapnur-
...entsareroa mended or olleud lot Sala.I I.Imwcvcr,the building GAS-EA.SYSTEM-1 1 NC.4 OUTLETS 6.00
or improvennnt is Sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA) 2.00 BUILDING uSE
builder will have the burden ul proving lh:d he did nm buildor int RES IND CON PB Omar
prove forpugmee of sul..L INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑
❑ I,as owner of the Property,anh exclo,ively contracting with
IIL'ell,ed C.In Ianon to 1.1111111.( the pro,,,(Sec. 7044,Itmin.,, LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Profession.Cud.:'I'll,Contractor's Lianee Luw dues not apply
to an owner of properly who Builds or improv.,tlmmon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
mnr.et,for such projects with'e,nnnracWHsl licensed pur,uml lis
the Contractor's License Law, SEWER-SAN TAR YSTORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I aln...mpl under Sae.-,B.&P.C.for lhi, WATER HEATER W/VENT 6.00
reason
Owner Dom WATER SYSTEM 5.00
ACC.DATE ACC,FILE N0.
WORK It RS'COMPIiNSA1ION DBCLARAT'ION WATER TREATING EQUIP. 5.00
I hereby:d Orm that I live o erulwatc of consent to all-inalre' 20NING ENG.SITE NO.
or a entilinde of Workeri Con ensation Insurance,or a certified
copy thereof ISeu. 3800.Lah.C.),I,�
-� Policy'No. Com Pant-71T0"T1.0_•1� /�Lti
O ❑ Certihedopyisherebylunishcd. FIRE SPRINK ENERGY T-74
Z ZCamil'ic up' lx rile ah the 'ins 'tion do"'I'lt.
Y ❑
-z._`' MISC.- REFER TO ORD. ❑
Oj- PP icanl � +�} N Y [3 NE]
OC w CERTIBICA71i OF EXEMP'I'll NFKOSI WORKERS. PERMIT ISSUANCE 10.00 FLOOD2ONE A.L.U.C.
Lu COSII'fSNSATION INSURANCE PLG.CONTE. LIC.NO. PLG. V❑ NE] V ❑ At E]
Cl This xctiun need not m
be eupldnd it the permit i, for one TOTAL
hundred drill...1 S 100)or less,I
U O 1 emit,that in cit pnlunnwa'e at the work Iar which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall nm employ:my Person'a any nwnn.r o,as n,
U hecune sunken to the Workers'Coln Penwtion laws of C,Ihl'ornia J-�
UJ Due Applieanl ALTER OR ADD TO MECH. 5.00 BUILDING 33
} on NOTICE '10 APPLICANT: It. Her nmklng MR,C,Rilium of 1:,-
H 2 eruption,you Should beuone,ulq,O to tic Workori Cumpcu,m ion APPLIANCE 5.00 PLAN CHECK
provi,ion, of the Labor Code. you mat Jor.hwilh comply with FEE
U such provisions or this pcnnll,11111 be dented le"A,J. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
C'ONSTRUCT'ION LENDING AGENCY AIR HANDLING UNITIOVER I0,000O.EM.) 6.00 SEISMIC FEE G2_ ?
I hereby afflri that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the perloriunce of the work fur such this permil i,issued(Sec MICROFILM
3097,CR,.C.). HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's ddreddre HEATING UNIT(OV ER 100,000 B.T.U.)Lender's Address ELECTRIC
I certify Owt I(tae read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
• inforolution is correct. I ague In comply with WI city and county BOILER-COMP 13 H.P.Or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and stale law, relating lis building canstnlction, and
hereby uuhonu• representatives of this city to anter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
also v.....entinned property for ins Fenian is oma.
IW'I agree m sac., indemnity and keep norm.,, III,City oI' MISC.- REFER TO ORD.
upenlno against liabilities,juJgmnm, mals unit expense,IsLich PERMIT ISSUANCE 10.00 CONST.TAX
Huy >' way accrue .,hi'a said Cit' in om,egocus, of the
•r mIt u the,pa• II . MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL d3
S ure ul'APpliemm/Canu.nor Date
OFFICE COPY