9477 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENT[FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
9477 7
7 ADDRESS 10885 . No . Stel.lin Rd. L� I
9 BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
• I
OWNER'S _ PLAN CHECK VALIDATION
1
NAME Valle
y Church OTY. ELECTRIC PERMIT FEE
PHONE
CONTRACTORS NAME AcroRs OUTLETS-SWITCHES-RECEP 10.00/1.00
None LIC.NO, LIGHTING FIXTURES 10.00/1.00
CONTRAC
ADDRESSTORS PPLIANCES-RESIDENTIAL 4.00
'.ONE PANELS 10.00 DATE OF APPLICATION
ORRCHITEcr PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. ISIGNS TRANS. 3.00
nOGRESS ENG' SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 PA
JO
MOTORS SEE FEE SCH. PAID
ADDDRESSDRESS
SERVICE CHANGE 20.00 P17 I
wo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 ��" 1985
a o u 1 hereby affirm that I am licensed under provisions of Chapter 9
"' (commencing with Section 7000)of Division 3 of the Business and SSU N E DATE
mi Professions Code,and my license is in full force and effect. BLDG. ❑ V n MECH.
Z D m License Class Lic.Number
9z w Dale Contractor
< ,yH 3- J' BUILDINGt ERMIT
¢ ¢ ¢ OWNER-BUILDER DECLARATION f INFORM TION"
w3: e N I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD I '
u0¢ Law for the following reason.(Sec,7031.5,Business and Professions VALUATION S/FT.
- PERMIT ISSUANCE 10.00
im 3 Code:Any city ar county which requires a permit to construct,alter.
S, Q¢Q Improve,demolish,Or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
D I[ requires the applicant for such permit t0 file a signed Stanton,n that TOTAL PF�MIT TO
a w $ he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000)ofl7ivision 3 ofthe
¢' Business and,Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ r $ the basis for the aIle ed cxem lion.An
g p yviolation Of Section]031.5 STORIBIS VPE CONSTR.
by any applicant for a permit subjects the applicant loa civil penalty ALTER-DRAIN& VENT-WATER IEA.) 5.00
of not more than five hundred dollars(S500)J:
❑ 1,as..net of the property,or.my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.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
Code. The Contractor's License Law does not apply to an owner of
Property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,Provide)that such im building
ments are not intended Or offered for sale.If,however,the building GAS-EA.SVSTEM-11NC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner
builder will have the burden of proving that he did not build or im. GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 3000 IND CON PB Other
❑ I,as owner of the property,am exclusively contracting with .
licensed contractors to construct the project(Sea 7044,BusinessLAWN SPRINKLERS-1 INC 5 V.B. 600 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply .
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 contractOns)licensed pursuant to
the Contractor' License Law SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
❑ 1 x• under ,BAKC.for this WATER HEATER W/VENT 6.00
reason
- f5w _ Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE No.
WORKI' C MPENSA'PION DC:CLARATION WATER TREATING EQUIP. 5.00
I hereby afNrm hal I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,Or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-
Z Z ❑'Certified copy is Pled with the city inspection division. Z4
Y N� V 24
Applicant MISC.- - REFER TO ORD.
w CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 0 FLOODZONE A.L.DC.
UJ > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
IL Z( This section need not be completed if the permit is for one TOTAL /p V N� Y N�
hundred dollars($100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL Umit is issued,I Shall not employ any person in any nmnner mas to
become subject to the Workers'Compensation Laws of California.
0. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE 1'O APPLICANT: If,after making this Certificate of Ex-
♦- Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions Or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10DWC.RM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT 100,000 B.T.U.)9.50
Lender's Address 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 /
ordinances and state laws relating to building construction, and BOILER-COMPLUMBINGP(3 H.P.Or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city t0 enter upon theaboveBOILER-COMP Maio 100,000 BTU)SEE FEE SCH. MECHANICAL
hereby
mauthored property tarvesp of
ection purposes.to
(We) agree to save,.Ind ify and keep harmless the City at MISC.- REFER TO ORD.
Cup no Igainst liabilities,ju gments, costs and expenses which CONST.TAX
To way acwe Agri t sa'd City in consequence of the PERMIT ISSUANCE 10.00
tih 1 t1 is permit H.CONT. LIC.NO. MECH.
i
TOTAL TOTAL
54afifivIo c nt o tractArxiare
OFFICE COPY