11936 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON PERMIT NUMBER
al11LDING r APPLICATION & PERMIT
noop s 'I� SirRWAA= A A BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 11936
NAMEOWNERS �w.�wL O�� PLAN CHECK VALIDATION
/I,�s y f, LE
(( " QTY. ELECTRIC PERMIT FEE
•,, AACWAGt A1ck LE0146INE
CONTRACTORSUTLETS-SWITCHES-RECEP
AME 10.00/1.00
N
LIC.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
NGINEER
LIC.NO. SIGNS TRANS. 3.00 -
ARCH.oRENG' SPECIAL CIRCUIT S.QQ PERMIT VALIDATION
ADDRESS
zap TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH. /J
ADDRESS
SERVICE CHANGE 20.00 -
0 02 LICENSED CONTRACTORS DECLARATION
< is u I hereby affirm that I am licensed under provisions of Chapter 9 ✓ ISSUANCE GATE
w< w (Commencing with Section 7000)Of Division 3 Of the Business and BLDG. ELECT. PLG. MECH.
H O i Professions Code,and my license is in full force and effect. ❑ ❑ ❑
z o T - License Class Lie.Number
Q ai F w Dale Contraclor .�f p,�y,jv
¢ x s J , oU BUILDING PERMIT
IS ¢ w¢ OWNER-BUILDER DECLARATIONINFORMATION
-
woAD MISC.- REFER TO ORD
;LL y I hereby affirm that I am exempt from the Contractor's License VALUATION S/FT.
aa u w. Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
¢ ¢ < 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
o Ic requires the applicant for such permit to file a signed statement that TOTAL
w 8 he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
Fi > Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe 1 /DZL46--
¢ Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT SEE
M 11- the basis for the alleged exemption.Any violation of5ection 7031.5 STORIES TYPE CONSTR.
c ;$ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(S50o.):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their Sale compensation,will do the work,and the structure is nor
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 5.011 50.FT,FLOOR AREA TOTAL ACREAGE
• himself re through his own employees,provided that such improve- GAS-EA.SYSTEM-1 INC.4 OUTLETS 6,00
meals are not through his or employees,
ffered ees,or provided
that
the building
or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im. BUILDING USE
RES IND CON PB olnar
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the properly,am exclusively contracting with Q
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 thereon,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. A=
TRACT NO. PARCEL NO.
IDI am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dat WATER SYSTEM 5.00 - ACC.DATE ACC.FILE NO.
WORK F-RS'COMPENSATION DECLARATION WATER TREATING EO I ,1i'd 5.00
I hereby affirm that 1 have a certificate of consent to set Ginsure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3600,Lab.C.). _ (� c+ -• ,
Policy No. Company
O ❑ Certified Copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection �s1Nf
O Applicant division. MISC.- 1zlQPEORD.
FERiT01 y N v N
iy CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 /O FLOOD ZONE A.L.U.C.
LU 2: COMPENSATION INSURANCES PLG.CONTR. ❑c.NO.O PLG. � - F] ❑N v❑ N❑
CL fThis section need not be completed if the per is for one TOTAL Y
LD Z hundred dollars IS 100)or to..)
U O 1 certify that in the performance of the work for which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mil is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
Q Ed Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} ran NOTICE TO APPLICANT': If,after making this Certificate of Ex
F. Z emption,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith Comply with FEE
V such provisions or Ibis permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 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 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 ELECTRIC
Lender's Address
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 �U
information is correct. 1 agree to comply with all city and county PLUMBING 1 -i
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP Over 100,00013TU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of misc.- REFER TO ORD.
Cope at ' if CS,JUIlginuents, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
a age' at said City in consequence of the
ran of /Q / MECH.CONT. LIC.NO. MECH.
Y/ 6 TOTAL TOTAL
re o plicnn[/Contractor Uale
OFFICE COPY