15011 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
aDILDING APPLICATION & PERMIT
A15011
D Ess
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL ,...
DINyNER'S PLAN CHECK VALIDATION
PHONE TY. ELECTRIC PERMIT FEE
(�J /V J
_ CONTRACTOR'S
NAME p OUTLETS-SWITCHES-RECEP 10.00/1.00
'• ONTR ���(�la ND.,' /n J LIGHTING FIXTURES 10.00/1.00
r,DrvrmacaoB's ,
APPLIANCES-RESIDENTIAL 4.00
PHONE J�� J PANELS 10.00 DATE OF APPLICATION.
RRCHITECT PANELS I OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.No. SIGNS TRANS. 100
ARC
ADDRESS ENG. SPECIAL CIRCUIT 6.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLICANT S MOTORS SEE FEE SCH. l\Uy\)r l '-
L`�'�Lf��(/t�/(C,l'.. v(JLj17� SERVICE CHANGE 20.00 S
0 0 0 LICI!NSEU CONI'RAC"TORS ULCLARA'I'ION
<z W I hereby uffinn that I am licensed under pnrvisiuns III Chapter 9 / p J�(j / _ )r) ISSUANCE GATE
(commencing with Section 70001 of Division 3 of the Bo,ine-,and
Gi < BLDG. ELECT. PLG. MECH.
r N i Professions Cole,ayJ my licence is in lull tilrcc�l J (i pt
z i n o License Cuss �( Lie.Number^ J 5/ ,
9 r w Date .a-' - Cmmocor 1 [
El 0
P: se 2 BUILDING PERMIT
IF be w a OWNER-BUILDER UECL\RAPION
a 0 o D INFORMATION
w ; LL „ I herel al lino that I not exempt Huns the Cnntrncmr's Lwi,nw. MISC.- REFE O OR
u
O< L'ew for the tilllowing reason.l5cc.7031.5,If usiucm and Professions VALUATION $/FT.
PERMIT ISSUANCE - _
Code'.Any city or county which spares a permit to cmdlruct,alter,
FO improve,demolish,or repair any structure,prior to its issuance,also ELEC.CO)NTH. LIC.N)O. 7 ELECbe . �a
Fi: 0, requires the applicant for such permit to file a signed statement that /�'U (' (�" �7(,Dy7[-// TOT[ ./
n w m he is licensed pursuant to the pravisiuna ml the Cunuactor'a License !r t )- - PERMIT TO
At Law(CImPter o(cornmeneing with 5eetion 70001 of Division lel the
E i o Business and Pole,,wns CuJe)nr that he is exempt theretrunl Full QTY. PLUMBING PERMIT FEE
H e the basis for the Alleged"enlptiun.Any sio"ation At Section 7031,5 STORIES TYPE CONSTR.
by any'a,,Ii,ARI Ibr a permit aubjeela'the appIwAnt lea civ it penalty
of not tore"hon I ise hundred dollen(S500).1: ALTER-DRAIN& VENT-WATER (EA.) 5.00
❑ 1,as owner of me property.nr mY enlplryccs wish wago'''s BACK FLOW PROTECT. DEVICE 4.00 DCC.GROUP RES.UNITS
their sole cimpensution,will do the wart,old the st nonce is nm
intended or offered for sale (Sec. 7044, Business and Prulessions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Con Vac[or',License Lax'dues not Apply m Am uwuer of
properly who builds or imposes thereon,and who dn,Y such work F IXTUR ES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTAL ACREAGE
hinself or through his own ernployeea,provided out such inglrose-
• meats are not inmould ur 1111elld l or ss lc.If,Iowcvcr,the build"', GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or inlprovemmnl is sold within one year of completion,the owner-- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden Or proving lhrd he did nut build or inn1,A,ownener r of the HES IND CON PB Oma,
❑ I,as o
Prove of sale.. INDUSTRIAL WASTE INTER. 30.00 11 ❑ ❑ El ElPopcny,a unuo
sdusivcly acting with
licensed contractors Io construct the project;See 7044.Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Prol'eviona Cod, I'he Cmuoeor i License Law duos not:q'ply'
to an owner of property who builds or improves thereon,and who LAWN SPR INKLERS-OVER 5 (EA.) 1.00
comrucu l'orsuchprujccts wi(ha:onir,ewi,)iiacna.0 p...... lni SEWER-SANITARY-STORM EA.200fI/10.00
the Cinit ac Wli Llcenw Law. TRACT NO. PARCEL NO.
❑ Iwo exempt under Sec. ,I1.N1'C.for this
reaamll WATER HEATER W/VENT 6.00
O"nen Dale WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
%i'ORKI-RS'CONPIiNSNI'ION DLCLARA TION WATER TREATING EQUIP. 5.00
1 hereby allion 11121 1 have a L11tiritcall of consent o,e"binsslre.
or a cenitic:ue of\Yorker:Cuntpcllution Insuru eo,or A cerlilictl ZONING ENG.SITE NO.
copy thergai(See 3N00.Lub.C'.I._
Policy N'm.'211 L/Sl1J:1�1L111'any 5aak�L[:.Yap_Id$- aKI-
0 ❑ erlilieIlh
pyiserr y'It i,I d FIRE SPHINK ENERGY PTO
n
Z 2 r✓ C,IT
l•�I[ �gv is/I}d 1 tllo 'I., in""'ion division.
F O Appllmi.y1,1.4_L` IC(1 'Ci`w� MISC.- REFER TO ORD, y ❑ N❑ Y ❑ N❑
CCm CER'1'IFICAI'I-OF E.N':.!d'I'ION]:Rut WORKEKS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
Luh CQ'sIPUN'SAII0N INSURAN(''Ii PLG.CONTR. LIC,NO. PLG
0 2 This wcltun nccd not he cmnpleled it The• Pennii is for one TOTAL Y❑ NE] Y ❑ NE)N
U O ItunJmd Jullary 1 i 001 or L•a.l
I andy Ibv nn my penins nroncc of me wort.Ibr which this per CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U rnit is issued.I shall not cnlpbyany person in any'manner so As o
become subject to that N'orkeri Qvupenvtion Law's to California.
0n Wte Appliaunl ALTER OR ADD TO MECH. 5.00 BUILDING
>_ ED NOTICE *1'0 APPLICAN"I''. "i,alter nwking This(',Hili,Ae ul Pa-
F 2 emptor.Sou should bcconle object m Tho Wonk,,,'Confi'cns:liun APPLIANCE 5,001 PLAN CHECK
proaw.ns of the Labor Code, you mot In-thwHil eooqu, wish FEE
U such prmvisiars or this permit shag be Lened r,,ok,d. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
C'ON'ST'RUC'TION LENDING AGENCY AIR HANDLING UNITIOVER 10=C.FM.) 6.001 SEISMIC FEE
I hereby uffinn Ihal there is a construction lending agency]or EXHAUST HOOD(WITH DUCT) 5.00
the perlornmHee of(lie work lot which this permit is issued 6l,,. MICROFILM
3097,Civ.C.), H EATING UN IT(TO 100,000 B.T.U.) 8.00
Lender',Adore• H EATI N G UNIT(OVER 100,000 B.T.U.)9.50 /C-SO
Lender's Address ELECTRIC
I ccnil'y lhat"base ct. I gree applicat ion and al:nrulal d above VENTILATION FAN (SINGLE) 4.00
inforinalion is correct.l I agree to comply with all oily and muoY PLUMBING
uNinmlces and slate laws n•Ialing Io building comtruclimn, and BOILER-COMP(3 H.P.Dr 100,000 B.T.U.) 6.00
�. • hereby lotio ed representatives ec this city to annr upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL \
hereby authorize
property lmrimsp of h purposes.
(WI) agree 1m save• indemnify and keep I m ole,s Ibe Cita rel MISC.- REFER TO ORD.
operon. a,Finsl "iAbdities,judgumno. culls amt eape'ses w'Iridr CONST.TAX
may in any way uc>rue against said city in eunw,luc c, of the PERMIT ISSUANCE 10.00
granting of This pcnth' MECH.CONT. LIC.NO. MECH.
OTAL TOTAL
Signature ul Applicant/Gnurmlor Dam
OFFICE COPY