11513 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDINGP OJECT IDENTIFI ION PERMIT NUMBER
BUILDINGJ�J v / APPLICATION & PERMIT 11513
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWN,
w "5 /�• PLAN CHECK VALIDATION
NAME 7��J/ Y. ELECTRIC PERMIT FEE
� PHONE
1 CONT
NAME 1� UTLETS-SWITCHES-RECEP 10.00/1.00 A ' D
NAME /y
ue.NO, LIGHTING FIXTURES 10.00/1.00
CO
T PPLIANCES-RESIDENTIAL 4.00 JUN 22
r
PHON PANELS 10.00 DATEOFAPPCIC'ATION
PANELS (OVER 200 AMP) 20.00 P(OI JZFVEEux P.C.NO.
ENGINEER
LIC.NO, SIGNS TRANS. 3.00
ARCH.SS off ENG, SPECIAL CIRCUIT 6.QQ PERMIT VALIDATION
ADDRE
ZIP EMP,METER OR POLE INS. 20.00
aP CANT
s . MOTORS SEE FEE SCH.
A aG 5438
SERVICE CHANGE 20.00
�
00 LICENSED CONTRACTORS DECLARATION
Q U v I hereby affirm that I am licensed under provisions of Chaplet41 ISSUANCE DATE
Haw (commencing wit Section 7000)of Division 3 o t B si ss' u ,. r. BLDG. ELECT. PLG. MECH.
w z Professions Co 1 license is in full force e
z O w- License las. Lic.Numher _ _ 1
4 m�-w Dare Contractor Pill
¢ y s � BUILDING PERMIT
¢ ¢ w O 'R-BUILDER DF,CLARATIO INFORMATION
w3 n a 1 hereby affirm that 1 am exempt from the Contractors License VALUATION $/FT.
r u 0 j Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
m Code:Any city or county which munitesa permit to construct,alter,
¢ rt Q 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
-O¢ requires the applicant for such permit t0 file a signed statement that TOTAL - PERMIT TO
n w m w he is licensed pursuant to the provisions of the Contractor's License
F z a Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
ar 1=-O the basis for the alleged exemption.Any violation of$ection7031.5 STORIES TYPE CONSTR.
a ; by any applicant for a permit subjects the applicant ton civil penalty
of not more than five hundred dollars($500R.) ALTER-DRAIN& VENT-WATER (EA.) 5.00
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 DCC.GROUP RES.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. 5.00
Cade:The Contractor's License Law does not apply to an owner of
• property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,fire owner- GAS EASYSTEM.OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or im - .- BUILDING USE
prove for purpose of sale.). - INDUSTRIAL WASTE INTER. 30.00 RES IND CON ps Orion
❑ 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. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves Ihercon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec '41_,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.GATE ACC.FILE NO.
WORKERS'COMPF-NSA'FION DECLARATION WATER TREATING EQUIP. 5.00
I hatch IT that I have a certifle ofcunsent to I-insure, ZONING ENG.SITE NO.
or u c ul•o rakers'Com'ens!M Ipsuruh ,I certi"al
co T - 00 p .y o .
Pol off o.........
an
Q rtilicdc p lsl yfu mi mire FIRE SPRINK ENERGY T24
Z Z ertificd copy filed I the city inspection division. MISC.- REFER TO ORD.
O Apman[ V❑ No V ❑ No
~ m PERMIT ISSUANCE 10.00
LU - CGRTI PICCOWI E I A'ION IN N WORKIiRS' FLOOD ZONE A.L.U.C.
UJ � COh1PENSATION INSURANCE PLG.CONTR. LIC.NO, PLG.
CL 0 Z ('f his section need not be completxtl if the permit is for one TOTAL Y❑ N❑ Y 11N❑
hundred dollar(S 100)or less.)
L) O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H 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.
W Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
I- Z emptor,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of time Labor Code, you must forthwith comply with FEE
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.NL) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction-lea ting agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued"cc. HEATING UNIT(TO 100,000 B.T.U.) 8.0 MICROFILM
3097,CR.C.).
Lender's Name
Lenders Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
0,000 B.T.U.) 6.00
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 10
hereby authorize representatives of this city to enter upon the BOILER-COMP IGVer 100,000 BTU)SEE FEE BCH. MECH ANI
ibovcanentioned property I'or inspection purposes.
(Wc) e
c indemnify and keep harmless the City of MISC.- REFER TO ORD.
Caper' o a ililies,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
ma m anrue against said City in consequence of the
g ruing Of It EC .CONT. UC.NO. MECH.
Signmure of Applicant/Contractor late
d2 TOTAL TOTAL /
OFFICE COPY