15254 APPLICANT TO FILL IN INFORMATION WITHIN'RED LINES - USE BALL POINT PEN ONLY
V BUILDING PROJECT IDENTIFICATION ` - " *- + .PERMIT NUMBER
BUILDING APPLICATION & PERMIT" r
AD R a 15254
AJ , /' �' UILDING — ELECTRICAL—PLUMBING—MECHANICAL
O EN'S '• ) _ PLAN CHECK VALIDATION
NAM OTA • ELECTRIC PERMIT ' FEE
1 L� ONE
CONTRACTORS
NAME n C�Q—V25S0 WIOUTLETS-SWITCHES-RECEPz, 10.00/1.00
,p
N. LIGHTING'6 LIGHTING FIXTURES 10.00/1.00 v.
CONTRACTORS ' " '•"' 'A
ADDREss- cp '] _ PPLIANCES-RESIDENTIAL' 4.00
,
6ZSSI t A4 ft AJ iVE#4,UNE -0T7 PANELS 10.00 DATE OF APPLICATION :
ARCHITECT. • PLAN CHECK FEE P.C.NO.
OR - ' PANELS�(OVER 200 AMP) 20.00
ENGINEER
• uc.No.'- µ � SIGNS TRANS: "_ 3.00 Q
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS s SPECIAL CIRCUIT 5.00 ' S 4 `'
zip EMP. METER OR POLE INS. 20.00 _
APPLICANT S- - / }-
ADDRESS"=r-' MOTORS ,;- SEE FEE SCH.
SERVICE CHANGE 20.00 E -
oo RIO
LICENSED CONTACTORS DECLARA PN
a u I hereby affirm thatI am licensed under Provisions of Cliapn' 9 n •1. ISSUANCE DATE -S
w G w (commencing Willi Section 7000)of Division 3 of the Business.Hd •,FAM- •BLDG. ELECT. PLG. MECH.
H 4D Professions Code'an license ism fulit, yul effe -.� - �,
oi w o Licwnse ass Lic.Number
H m H w Oam Contractor . pv
. a m 2 f3 MAl BUILDING PERMIT ;
¢ 2a OWNRR-BUILDER DECLARATION - '.,
SE a u •.. INFORMATION ':•.;
Z:
g u I hereby affirm that I am exempt from the Contractor's License - MISC.— REFER TO D
LL O J Law for the following reason.(Sec.7031.5,Businessand Professions `VALUATION $/FL
r — PERMIT ISSUANCE '
my Code'.Any city orcounty whichrequiresapermil In construct,alter, r:
Qua2 improve, or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO, ELEG. 'T•' `
i w m u requires the applicant for such permit IR file a signed statement that •• TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
Hzi
Law(Chapter9(commencing with Section 7000)of Division 3 ofthe -
a
f,4 D Business and Profession,Code)Or shot he is exempt therefrom and QTY. .PLUMBING PERMIT - FEE' l
K F$ the basis for the alleged exemption.Any applitido f Section malty - ° STORIES TYPE CONSTR.
di by any applicant fora permit subjects theapplicant too civil penalty ALTER-DRAIN&VENT-WATER IEA.) 5.00
OI'not more than five hundred Rollers(5500).1:. - _ •
' ❑ 1,as owner of the properly,or my employees Willi wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP. RES.UNITS
intended or offered for site (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5,00
Cod P:,The Contractor's License Law does not apply to an owner of '
properly who builds or.improves thereon,and who Roes such work FIXTURES-.PERTRAP ' 5.00 so.FT.FLOOR AREA TOTAL ACREAGE„
matshimself re of rote his own employers.Provided that such improve. -
mems me not intended or employee sale,provided
that s the building GAS-EA.SVSTEM-4 INC.40UTL ETS -6.00
or improvement is sold within one year of completion, the owner- GAS EA:'SV STEM-OVER 4IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did Hot build or ins -
prove for purpose ofsale.). ' INDUSTRIAL WASTE INTER. 30:00 RES IND ' CDN, ,PB _ Omer.
❑ I,as owner of the property=am exclusively contracting with - 0 El _0 . 1:1 1
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 Low does not apply - -
to an owner of propertywho holds or improves thereon,and Willi LAWN SPR I N KLERS=OV ER5(EA.) 41,00
contracts for such projects with a contructor(s)licensed pursuant to SEWER-SANITARY-STORM 200ft/10.00
file Contractors License Law, TRACTNO. PARCEL NO.
❑ I am exemP(under Sec. - BAP.C.to,this - 00
WATER HEATER W/VENT ` 6.
4 reason A -
Owner Date WATER SYSTEM . '5.00
ACC.GATE ACF FILE NO.
.WORKERS'COMPENSA1ION DECLARATION- WATER TREATING'EQUIP. 5,00 -
I hereby atfiim that l have a certificate ufconsem to self-insure. - -
or a certificate of Workers Compensation Insurance,of a certifier) ZONING ENG.SITE NO.
..- copy here 11 ; 0 Lah.C9
Policy,NoIf mpany 61l7
4e FUND "
I
Q Cl Certified copy is hereby furnished. - FIRE SPRINK ENERGY T24
z.Z Certified copy is filed with the city inspection division.
MISC.- REFER TO ORD.
O - Allhcant yEl .. NQ r0•: NO.
CC CERTIFICATE CERTIEICOIROAWORAERS' PERMIT ISSUANCE 10.00
RLDOD ZOrvE A.L.U.D.
W COMPENSATION INSURANCE
PLG.CONTE LIC.NO. PLG.
(This section need not he ccoro,led if the Permit Is for m - TTOAL Y❑ 'NE1 VC] NQ
hundred dollars(S 100)or less.)
U O 1 certify that in the perfarmunce of me work for which this per OTY, MECHANICAL PERMIT FEE FEE SUMMARY
U_ F mil is issued,I shall not employ any person in any manner so as to
O w become subject m the Workers m
Copensation Laws of California. " :G `
d Date Applicant BUILDING
} to NOTICE TO APPLIGW'C If,after making this Certificate of 5x- ALTER OR ADD•TO MECH. - 5.00
Fz enlplion,you should become suhject,to the Workeri.Compensalmn APPLIANCE ' 5.00 PLAN CHECK
provisions of the Labor forthwith Labor-COLIC, YOU comply wills FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT ITO 10=C.F.M.)
CONST RUCTION LEND]NG AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 'SEISMIC FEE
I hereby affirin`Ihal there is a construction lending a,cue,'1'm EXHAUST HOOD'(W ITH DUCT) 5.00 • -
the performance of Ilse work for which this permit is issueel(Sec. MICROFILM
. 3097,Civ.C.). HEATING jUNIT(TO 100,000 B.T.U.1 8.00
Lender's brine . '
HEATING UN IT(OV 100,000 S.T.U.)9.50
' Lender's AAJress ELECTRIC �77�
1 certify that I have read this application and slate that the above `+ VENTILATION FAN (SINGLE)'' -4.00
•� information is correct. [,agree to comply with all city and countY - PLUMBING
ordinances and stale lows relating to building construction, and iBOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the e BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned,property for inspection purposes. _
(We) agree to save, indemnify and keep harndess the City of MISC.- REFER;TO,ORD. '
u Perlin. against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX.
ay in any way accrue against said City in consequence-of the
•noting of this permit - p�-•.I., MECH.CONT. LIC.NO. MECH. -
\�( _ _-�%�� '•. ) '/.. � TOTAL' • TOTAL
J�j•Signature of onlicant/ tract�o IC' or Date "
OFFICEICOPY