14763 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
~ BUI LDI NG PROJECT 1 DENTI FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
wo _� CY/CN /n��C7� "w "ELECTRICAL-PLUMBING-MECHANICAL 1 4763_
DWNERS
PLAN CHECK VALIDATION
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E le _ ��. GTV. ELECTRIC PERMIT FEE
t V HONE
'x. C AcrGRs UTLETS-SWITCHES-RECEP 10.00/1.00 g
N IC,N LIGHTING FIXTURES 10.00/1.00 T/ /j
06" PPLIANCES-RESIDENTIAL 4.00 (i
pH ' PANELS 10.00 ATEOF APPLICATION
OR YYRc"ITE PANELS (OVER 200 AMP) 20.00 PLAN CHECgfEA ' D .c.NO.
O
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.
oo Ess ENa. SPECIAL CIRCUIT 5.00 f��^lIl`Of LfPAJion
94
TI, EMP.METER OR POLE INS. 20.00 111F1 era 2 9
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CANTS MOTORS SEE FEE SCH. L1pY C)
SERVICE CHANGE 20.00 5I?.•1/ I/%
oaa LICENSED CONTRA. RS DECLARATION
<U. I hereby af@m flat I am licensed under provisions of Chapter 9 ��✓ -' SSUANCE DATE
z w (commencing wish cll1n-70001 of Division 3 of the Businev a
7 i Nofatlions Code y�kjn3e is in full forte t BLDG. ELEOT. PLO. EC
oo av1- License Clan Iv LIc.Number ❑ ❑ ❑
w � w Dale Contractor
< s DATE 9 BUILDING PERMIT
¢ z a,,_S OWNER BUILDER DECLA ION INFORMATION
X
I hereby affirm that I am exempt from the Contractor's License MISC. - R FER TO ORD
'.o g Law for the following reason.(Sec.703 L5,Rmiaesand Prafe sions V ALUAT1oN SIFT.
� - Code:Any city orcounty whkhrequiresapermittownstmcl,alter, PERMIT ISSUANCE 10.00
¢¢ p Improve,demolish,or repair any structure.prior to its issuance,also ELEC.CONTR. LIQ NQ ELEC.
o LL Iequlres the applicant for such permit to file a sighed statement that TOTAL PERMIT TO
whe is licensed Pursuant to the provisions of the Contractors License
FiQLaw(Chapter 9(commencingwith Section 70001of Divi,nor fthe
4 o
Business and Profusions Code)or that he is exempt therefrom and QTY, PLUMBING PERMIT FEE
¢r$ the basis for the alielmd exemption.Any violation of Seclion7031.5 I STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil Penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
or not mote than five hundred dollars(SSW),I:
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 occ.cnouP RES.senses
their sole compensation,will do the work,and the structure is nut
intended or offered for sale (Sec. 7044, Boniness and Profenlons DRAINS-FLODR,ROOF,AREA,COND. 5.00
Code:The CorRractoi s License Law docs not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SM FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mems arc not intended or offered for sale.If,however.the budding GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
r improvement is sold within one year of completion.the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im' RES IND CON PS Otho
prove for purpose of sale.(. INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Rnslnes LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
god Professions Code'.The Contractor's License Law does not apply
to im owner of property who builds or improve,thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such projects with a contraclons)licensed Punoenl to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ la ex t underS BAP.C.for this WATER HEATER W/VENT 6.00
ream
Own Date WATER SYSTEM 5.00 ACQOATE ACC.FILE NO.
AIION DECLARATION WATER TREATING EOUIP. 5.00
e, y From(hal l h v a ce,tif''ate of courent to self-i nmm' ZONING
or a certificate of Workers'Compensation I s 2 c or ace tifw, ENG.SITE NO.
copy thereof l Sec.3800.Lab.'
policy No. Compao _
Q ❑ Clrli- it copy 11, 1 d m FIRESPRINK ENERGY TN
if
Z ❑ rrit-led Is bIAY ci nspection Ivluon. MISC- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
O Anpllcant
~ rnPERMIT ISSUANCE 10.00 EL000 ZONE A.L.u.c.
CIA .to-
OF E. EAII' UN PROM WORKERS'
W C MPF,NSATION INSURANCE: PLG CONTR. LIC.NO. vLGCL . Y[:] N❑ v E] N❑
Z (This section need not be completed if the Permit is for one TOTAL
hundred dollar,IS I W)or It.I
U O 1 certify that in the performance of the work for which thk per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL {-- cell Is iraued,I shall not employ any person In any manner m as In
V become subject to the Worken Compensation Laws of Califomia.
W
Dat° Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
? emption,you should become subject to(he Worken Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
C.1 well provisions or this r'ermil shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=Q_F.M.) 6.00 EISMIC FEE
I hereby affirm that there it a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the 3097,,E Iv performance of the work for which this penn0 V Isuted(Sec. HEATING UNIT(TO 100,000 B.T.U.) B.DO MICROFILM
Lender's Name
Lender's Address HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and slate Chat the above VENTILATION FAN ISINGLE) 4.00
information k correel. I agree to comply with all city and county PLUMBING -
ordinaoers and state laws relating to building construction, unit BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
s hereby authorise reptest.buives of this oily Iv enter upon the
above-mentioned property for inspection purposes. BOILER-COMP IOser 10(,000 BTUI SEE FEE SCH. MECHANICAL
t
agree tosave. cm iry end keep harmles the Clty of MISC.- REFER TO ORD.
ag obi'¢s, dgments, costf a1M expenses which CONST.TAX
n ac a test sa. City in consequence ra the PERMIT ISSUANCE 10.00
n pen ME H.CONT. LIC.NO. MECH.
S('O // TDTAL TOTAL
of Applicant/Contractor [Yale / / J
OFFICE COPY ✓e�Uu�