0959 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BU LDING PROJECT IDENTIFICATION PERMIT B R
57L5 'a APPLICATION & PERMIT
BUILDING— ELECTRICAL—PLUMBING—MECHANICAL 959
OW E 's
NAME 1. . :�"' '.c '• T•^.,'[" -r.
DTV• : �',r./' � • r. u' r r '. PLAN CHECK VALIDATION
• .ELECTRIC PERINIT; -.' FEE'
PHONE :1P: ,n', '•, , ... i .,.n'XT -.. . ......
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CO - '-'
AN..TkA^SC�Tt,O�iHS
��j3, UTLETS-SWITCHES-RECEP 5.00/1.00
:�C( o. LIGHTING FIXTURES .5.0011.00
REsPPLIANCES-RESIDENTIAL 4.00
PHONE PANELS
RCHITEC 5.00 DATE OF APPLICATION
on
ENGINEER SIGNS 6.0 PLANCHECK FEEP.C.E =
PC
SIGNS TRANS. r 3.
ADDRESS
ADEN4
REss SPECIAL CIRCUIT S. PERMIT VALIDATION
APPLICANT'S
ZIP EMP.METER OR POLE IN 15.0
"OGRESS MOTORS E FEE SC
W ¢z
SERVICE CHANGE 0.
Foo LICENSED CONTRACTORS DECLARATION alas '
a i W I hereby affirm that I am licensed under provisions of Chapter 9
as
a (commencing with Section 7000)of Division 3 0(the Business and ISSUa CE DATE
iO'� Professions Coda,an license is in full fore and Err« BLDG. ELECT. PLG. MECH.
:G License lass Lic.Number - ❑ ❑ ❑
IA F w Darn-��� �Comrectar n a
0 -
¢ J
u, a OWNER-BUILDER DECLARATION � , -:,^a�BUILDING PERMIL,^j;
O LL N I hereby affirm that I am exempt from the Contractor i License' MISC.— REFER TO ORD - .',INFORMATION';,,. ,_•
ww O a Law for The fo0owing reason.(Sec.7031.5,Business end Professions PERMIT ISSUANCE -'VALUATION B/FT. o
� � Code:Any city or county whichrequircsa permit toconstruct.alter. 6.00
a g0 improve,demolish,ar repair any slTucturc,prior to its issuance,also ELEC.CONTR. LIC.NO. �/�
o W requires the applicant for such permit Io file a signed statement that ELEC.
X y his licensed pursuant to the prOvialOas of the Contractor's License TOTAL PERMIT TO
Fz> Law(Chapter 9lmmmencin9 with Section 7000)of Division 3 o(the ° e :P, }
s z c Business and Professions Code)or That he is exempt Therefrom and OTY rr .,vY PLUMBING PERMIT' 1' "f FEE' /x�•�r�e f
ic I- the buss for the alleged exemption.Any violation of Section 7031 5 Y
e.3.. by any applicant for a permit subjects the applicant Ina civil penalty ' '"� - s"�"'c ^-r`^'i - ''S:; STORIES TYPE CONSTR.
of not mart Than five hundreddollars(5500).): ALTER-DRAIN&VENT-WATER (EA.) 4.00
❑ 1,as owner of the property,or my employees with wages as
their sole compensation,will do the work,and the structure is not BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
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
properly who builds or improves thereon,and who does such work F IXTUR ES•PER TRAP 4.00
himself or Through his own employees,provided that such Improve. a0.FT.FLOOR AREA TOTAL ACREAGE
mentsarc nolinlended or offered for sale.If,however.The building GAS-EA.SYSTEM-11 4.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of-proving that he did not build or int- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
prove f.a,owner
of the
I NDUSTRIAL WASTE INTER. 20.00 RES IND CON PB Other
❑ d as owner of the property,he exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors To construct the project(Sec. 7044,Business
and Professions Code The Contractors License Law does not apply LAWN SPRINKLERS- 71NC5 V.B. 5.00 ASSESSORS PARCEL NO.
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 contracim(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00
on
❑ 1 am exempt under Sec. ,B.&PWATER HEATER W/VENT.C.for This TRACT NO. PARCEL NO.
400
Date
reas .Owner
WATER SYSTEM 4.00 ACC.DATE ACC.FILE N0.
WOfirm that
have a "TION DECLARATION WATER TREATING EQUIP, q,Op
I hereby affirm That I have m e Compensation
of ronsent to self-insure
or a certificate of Workers'Compensation Insurance,or a certified ZONING
copy thereof l Sec, OALab.C.)'S C t - ENG.BITE N0.
Policy N C pat � _L-AaM nc fj
❑ Certified copy is hereby furnished.
❑ Certified CO FIRE SPRINK ENERGY TZ4
Z PY is filed with the city inspection division.
O Applicant MISC.- REFER TO OR Y ❑ No Y C] N[]
C H CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00
LI COMPENSATION INSURANCE FLOOD ZONE
CONTR. LIC NO.(This aPLG. PLG.
Z
ction need not be completed if the permit is (or one TOTAL v N� v N�
O hundred dollars(5100)or less)
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 t0 QTY. MECHANICAL PERMIT FEE FEE SUMMARY
W become subject to the Workers Compensation Laws of California.
- ZQ. Dale Applicant BUILDING
NOTICE TO APPLICANT: 1(,after making This Certificate of Ex- ALTER OR ADD TO MECH. 4.00
emption,you should become subject To The Workers Compensation APPLIANCE provisions of the Labor Code, you must forthwith comply will) 4'00 PLAN CHECK
such provisions or this permit shall be deemed revoked, AIR HANDLING UNIT(TO 10=C.F.M.) 3.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT IOVER IO.OWC.EM.I 5.OD SEISMIC FEE
I hereby affirm that there is a construction lending agency for V v
EXHAUST HOOD(WITH DUCT) 2.00
the Performance of The work for which this permit is issued(Sec.
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
Lenders Name
Lenders Address HEATI NG UN IT(OVER 100,0008.T.U.)7.50 ELECTRIC
I certify that I have read this application and slate That the above VENTILATION FAN(SINGLE) 3.00
information is correct, I agree 10 comply with all city and county
rdi...of, and stale laws relating to building construction and BOILER-COMP 13 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
*reby authorize representatives of this city to enter upon The
ove-mentioned property for inspection purposes. BOILER-COMPho 100,000 BTu15EE FEE BCH. MECHANICAL
(We) agree To save, indemnify and keep I e Icss the City of MISC.- REFER TO ORD.
.uperlino against liabilities,judgments, costs and expenses which
May M any way accrue against said City in consequence of the PERMIT ISSUANCE 3,00 CONST.TAX
yy�+�g yf Thla Pcy�IT. MECH.CONT. LIC.NO. MECH.
}iedt 41 a Jsiot/1 q �Q/ TOTAL TOTAL:, 39 0 0
&snuture of Applicant/Cintractor tc
OFFICE COPY