9505 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT 1 DENTI FICATION PERMIT NUMBER
9.IL.INSG APPLICATION & PERMIT
AODness/
�" BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 95
05
OWNER'S y ry IRN + ' PLAN CHECK VALIDATION
Nn�m1e /�. 1-�s- 41?QTY. ELECTRIC PERMIT" FEE
JIGN .ONE ���I�
nnme ACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
�I N fCR�IfN J/,C.No, LIGHTING FIXTURES 10.00/1.00
CO.NTRACTORS - PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
on PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG. PERMIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 -
ANT'$
ADDDRESDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 Ca 1
w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE '30.00
¢a u v 1 hereby affirm that I am licensed under provisions of Chapter 9
Z w ISSUANCE DATE
N 4 N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F o z Professions Code and my tic use is in full force and effect.
o i o License Class m.Number
Dale_ ���iii��'��'��'TTT Contractor IN
Q y E J
¢ ¢ w 4 OWNER-BUILDER D17CLARATION ) BUILDING PERMIT
° ° " MISC.- REFER TO ORD INFORMATION
E:
C LL y I hereby affirm that I am exempt frnns the Contractor's License
0 4 Law for the following reason.(Sec.7031.5,Busineeeand Professions VALUATION
., PERMIT ISSUANCE 10.00
Pw�4 Code:Any city or county which requires permit toconstrud,alter, rA
¢ ¢ 4 0 Improve,demolish,or repair any structure,prior to its Issuance,also ELEC.CONTR. LIG NO. ELEC. "
F O¢ requires the applicant for such permit to file a signed statement that TOTAL
PERMIT TO
u w m a he is licensed pursuant to the provisions of the Contractor's License
r z t L..(Chapter 9(commencing with Section 7000)of Division 3 oflhe �I.QL�T-4'✓� S/4.Jg
4 o Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE.
¢ F $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
e. , by any applicant for a permit subjects the applicant to a civil penalty ALTER -WATER (EA.) 5,00
of not more than five hundred dollars($500).1:
C I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not'
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SD.FT.FLOOR AREA TOTAL• himself re through his own employees,provided that such improve-
ments impro menot den old or within
red one or year OIhowever.tile the owner-
GAS-EA.SYSTEM-11NC.40UTLETS 8.00
or improvement is sold within one year that
completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or int- BUILDING USE
prove for 1,as owner
of theJ. INDUSTRIAL WASTE INTER. 30.00 'RES IND CON PR eine.
❑ d as owner of the property,he exclusively contracting with ❑
licensed contractors to e Contra the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's s License s th does not apply
to tr owner of properly who builds t r improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contmctorl sl licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10,00 TRACT NO. PARCEL NO.
❑ [am exempt tinder Sec..,B,&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKFRS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
L copy thereof(Sec.3800,Lab C.).
Policy No. Company '
O ❑ Certified copy is hereby furnished FIRE$PRINK ENERGY T-24
Z Certf op
iy�' "le w R he city inspection division.
F - Ap❑plicant �lt MISC.- REFER TO ORD'. Y� N� Y [:] N�
y CER'rIFICAT140F EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
L COMPENSATION INSURANCE PLG.CONTR. .LIC.NO. PLG.
C ('Chis section need not be completed if the permit is for one TOTAL Y[:] A[] Y ❑ No
0 Z hundred dollars($100)or less.) -
U O 1 certify that in the performance of the work for which'Isis per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL ♦- mit is issued,I shall not employ any person in any manner. as to
U become subject to the Workers'Compensation Laws of California.
0 0. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING / Jv
>_ W NOTICE TO APPLICANT: If,after making this Certificate of E.. -•�
F ? emption,yen should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK 2
provisions of the Labor Code, you must forthwith comply with U FEE such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4,00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10PMC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
inforinformation is correct I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
mtio and state laws relating to building construction, and
hereby entioed representatives forms of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE$CH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cuper line against liabilities,judgments, costs and expenses which CONST.TAX
ED in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
gm n fthis pe MECH.CONT. LIC.NO. MECH
4 6 &t TOTALTOTAL
ignature.rA plicant/Contractor Dal
OFFICE COPY