2497er.
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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT 1 DENTI FICATI ON
APPLICATION &PERMIT
BUILDING -ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
/� (I �]
2 4 J I
BUILDING
ADD E33
1
O/wNER'SW
"AME �/�n '
r M'',,
1 I , a�� / I E
DTV r I - ELECTRIC PERMIT, 'hr,k ":g� FEE}a�
r W' t ,' ; tdf K' %)y'liK b 4•'j#Y.wF� 1 7ti
PLAN CHECK VALIDATION
• NAMERACTO
UTLETS-SWITCHES-RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
LIC. No.
CONTRACTORS O �)APPLIANCES-RESIDENTIAL
ADDRESS 4J -��
4.00
PANELS 5.00
SIGNS 6 QQ
PHONE
ARCHITECT
OR
ENGINEER
LIC, ND.
DATE OF APPLICATION
.
PLAN CHECK FEE P.C. 70-
.J QQ
SIGNS TRANS.
AARCH. OR DDRESS ENG.
SPECIAL CIRCUIT S.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 15.00
ZIP
APPLICANT'S
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
/ !�
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9
ISSUANCE DATE
(commencing with Section 7000) of Division 3 of the Business and
BLDG. ELECT.
PLG. MECH.
Professions Code, and my license is in full force and effect.
License Class Lic. Number-
s-�I ❑
I
O
Dam Contmctor
OWNER -BUILDER DECLARATION
I hereby affirm that I em exempt from the Contractor's License
Law forthe fa8owingreason.(Sec. 7031.5. Businessand Professions
Code: Any city or county which requires permit to construct, alter,
improve, demolish, or repair any structure. prior to its issuance, also
Fa+a,^,TIN FORMATION R^-;,'.�)(s;.
-'
MISC.- REFER TO ORD
VALUATION
6 Q Q
S/FT.
PERMIT ISSUANCE 6.00
ELEC. CONTR. LIC. NO.
ELEC.
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's Limme
Law(Chapter 9(commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom end
the basis for the alleged exemption. Any violation of SO 7031 5
TOTAL
PERMIT TO
F.�� ,-� .2,i,d l(,X.t
. -
" - 11' }rs' "T ,' s w!' .- r"^-,�
DTY 5.,'PLUMBING PERMIT lxr-ki FEE;
kr..' t: e'• ± .i+lrv--,:",+.' r.L;. 'w'.. :"�
STORIES
TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (5500).):
ALTER-DRAIN-WATER(EA.)4.00
0 [,as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
intended or offered for ale (Sec. 7044, Business and Professions
IBACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
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 4.00
SD, FT. FLOOR AREA
TOTAL ACREAGE
himself or through his own employees, provided that such improve-
mentsamnot intended oroffered for sale. If, however, the building
GAS - EA. SYSTEM -1 INC.4 OUTLETS 4.00
•. or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or int.
r ve for purpose of ale.).
1, as owner of the property, am exclusively contracting with
monad contractors to construct the project (Sec. 7044, Business
GAS - EA. SYSTEM - OVER 4 (EA.1 1.00
BUILDING USE
RES IND CON PB Omar
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
ASSESSORS PARCEL NO.
and Professions Code: The Contractor's License Law does not appy
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 contractods) licensed pursuant to
the Contractor's License Lew.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 4.00
❑ lam exempt under Sec.-, W&P.C. for this
IT So
Date owDe
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO,
WORKERS'COMPENSATION DECLARATION
WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to self -insure.
or a certificate of Workers Compenation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof ( Sec. 3800, Lab.CLn .sem
Policy No. Company f� H
❑ Certified Copy Is hereby furnished,
FIRE SPRINK
ENERGY T-24
❑ Car' is copy is f4 d with the city inspection division.
App11c -
Y ❑ N❑
Y ❑ No
MISC. - REFER TO ORD.
PERMIT ISSUANCE 6.00
FLOOD ZONE
ALU.C.
ee
CERTIFICAT FEXEM ORl'�-
PLG. CONTR. LIC. NO.
PLG.
TOTAL
COM F.NSATION INSURANCE
(This section need not be completed if the permit is for one
Y ❑ No
Y ❑ N❑
_-- - -
OTV. '. MECHANICAL PERMIT FEE
-
-
FEE SUMMARY '-
hundred dollRrs(SIGO)orless.)
I certify that in the performance of the work for which this per.
mil is issued. I shall not employ any person in any manner so as to
become subject to the Workers' Compensation Laws of California.
Date ApplicantALTER
BUILDING
OR ADD TO MECH. 4.00
NOTICE TO APPLICANT: If, after making this Certificate of Lu
emptien. you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
APPLIANCE 4.00
PLAN CHECK
FEE
`
AIR HANDLING UNIT (TO 10=C.F.rNAU 3.00
AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued ISec.
3097, Civ.C.).
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
Lender's Name
Lender's Address
I cwr ly that 1 have read this application and stale that the above
information is correct I opera ro comply with all city and county
ordinances and state laws relating to building const ruction. and
VENTILATION FAN (SINGLE) 3.00
PLUMBING
BOILER-OOMP13 H.P. Or 100,000 B.T.U.) 4.00
BOILER -COMP IOver 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
CONST. TAX
(We) agree to ave, indemnify and keep harmless the City of
Cu actino apoinst liabilities, judgments, costs and expenses which
ay 'n any we accrue against aid City i consequence of the
nlf lh' IT .
q a (�
PERMIT ISSUANCE 3.00
MECH. CONT. LIC. NO.
MECH.
TOTAL
+. -
TOTAL.
y S�
Ignatur Of pplicaat/Contmctor Uam
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OFFICE COPY