5423 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES = USE BALL POINT PEN ONLY
13U LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
x ADDRESS
\ BUILDING —'ELECTRICAL—PLUMBING—MECHANICAL_ 5423
OWNER'S - PLAN CHECK VALIDATION -
"A' OTY. - ELECTRIC PERMIT _ FEE
' ��+r -1 PHONE V V /V
GTOfls
NASBE - UTLETS-SWITCHES-RECEP 5.00/1.00 '
NAME
To.No, LIGHTING FIXTURES.. 5.00/1.00 -
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS ' ' 5.00 . DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OO
ENGINEER a - Lie.No' SIGNS TRANS. 3.00
AARCH.OR DDRESS ENG - r SPECIALCIRCUIT '5.00 .PERMIT VALIDATION '
xlr EMP.METER OR POLE INS. 15.00 .
ADDRESS rs
ADDRESS MOTORS ' SEE FEE SCH. r ��
SERVICE CHANGE 10.00
., o o 'LICENSED CONTRACTORS DECLARATION r
QUv Iherclay affrnlhal I an liceived under provisionsof Clmplei,9 ISSUANCE DATE
as (commencing will,Section 7000)of Division 3 of(Im Ititsiness and BLDG. KN ,
3 z Professions Code,and my license is in full force and effect. ❑o m— License Class I.it.NumberLJJ Late Contract",rz OWNER-RII1LUIiR DECLARATION . n• IAFKUI D o a - - MISC.— - .REFER TO ORD
wg LL y I hereby affirm that'I wn exempt from the Contractor's License _ -
LLNa haw for the following reason(Sec.7031.5,BusinessanJ Professions PERMIT ISSUANCE ' - 6.00JsAT�uCode:Any city or county which requircsapermil to construct,alter,0improve,demolish,or repairany structure,prior to its issuance,also ELEC.CONTR. '" LIC.NO. ELETCw m requires the applicant for such permit to file a signed statement that TOTAL - PER
he is licensed parsuanl to the provisions of the Contractor's License '
H z a Law(Chapter 9(commencing with Section 7000)of Division 3 of the - �'N � �"-77
4 0 'Business and I'ro1'esxb s Code)ar that he is exempt therefrom and CITY. 'PLUMBING PERMIT - FEE.
a I- the basis for the alleged exemption.Any violation of$ecima 7031.5 1 STORIES TYPE CONSTR.
ni � by any applicant for a permit subjects the applicant ma civil penalty ALTER-DRAIN&+VENT-WATER (EA.) 4.00
' of not more than five hundred tell...(S5000.) -
O 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEV ICE' 2.00 •OCC GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not _
intended ar offered for sale(Sec. 7044, Business and professions DRAINS-FLOOR,ROOF,AREA,GOND. 4.00
Code:The Contractor's License Law does not apply to an owner of _
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP - 4.00 SO.FT.•FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered far sale.IL however,the building GAS-EAPSYSTEM-1 LNC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) . 1.00 BUILDING USE
builder will have the burden of proving t ut he did not Inild or im-
proveforPurposeofsale.). •. INDUSTRIAL WASTE INTER. 20.001 RES IN CON PB .0
❑, I,as owner of the property,.am exclusively contracting with _ ❑ ❑ ❑ 1:1
'❑
licensed contractus to construct the Project(See.7044,,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Cotte:T he Ctioloictor'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 confacloos)licensed pursuanflo
i' the Cmvrnewrs License Law. SEWER-SANITARY-STORM. EA:200ft/8.00 - TRACT NO. PARCEL NO.
❑•'I am exempt under Sec. - ,BAP.C.fur this WATER HEATER W/VENT 4.00
renwn
Dote — WATER SYSTEM. '.4.00' Ace.DATE ACO,TILE N0.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate ofconseiht to self-insure,
or a certificate of Workers!Compensation Insurance,or a certified ZONING ENG.SITE NO.
Copy thereof(Sec.3800,Lab.C.L - } -
policy No. - Company - -
Q ❑ Certifiedcopy is hereby furnished FIRE SPRINK ENERGY T 2 '
Z Z, ❑ Certified copy is fled will, the city inspection division. -
O Applicant +, MISC.- REFER TO ORD. Y IN F] Y'[:] N❑
. y CERTIFICATE OXF.MI'TION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
CC P EXEMPTION
> COMPENSATION INSURANCI ,PLG.CONTR. - LIC.NO. PLG.
d (This section'need not be completed If the permit is for one Y TOTAL Y❑ N❑ Y [:] N❑
Z hundred chdars(SIO00 or less.) r -
U O I certify that in the performance of Ibowmk forwhich this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY.'
LL H 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.
ad Date—Applicant- - • BUILDING
. ALTER OR'ADD TO MECH., 4.00 -
} m NO'I'ICE'10 AI'I'LICAN'1': If,aNer,making this Certificate of rix- .
FZ emption,you should become subject to the Workers'Compensation APPLIANCE ', r 4.00 PLAN CHECK / 37
,provisions of the labor Code, you must forthwith comply with .FEE /(
U; such provisions or this permit shall be deemed(evoked., AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
., CONSTRUCTION LENDING AGENCY AIR HANDLINGUNIT(OVER 10=1C.EM) 5.00 SEISMIC FEE 570
(,hereby affirm tlia( IItem is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this Permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00 _
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 -
Lender'sAddrcsa ELECTRIC t• '
Icertify that l have read diisupplication and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct.1 agree(o comply with all city and coomly PLUMBING ' '-
-. ordinances and state laws'relating'to building construction, and BOILER-COW13 H.P.Or 100,000 B.T.U.) 4.00 _
hereby authorize representatives of this city to enter upon,the BOILER-COMP,(Oser)D0,DDO BTUI SEE FEE SCH. 'MECHANICAL
Ain
oned properly for inspection purposes.,, I,
wve, indemnify and'keep:harmless'Ihc City of MISC.- REFER TO ORD.
in 1ilitics,j dgmenis, costs and,expenses which' ' CONST.TAX
ee aga' id,City in consequence of the. PERMIT ISSUANCE ,3.00 MECH.CONT: LIC.NO. MECH.TOTALTOTAL p can Cram Date "
r .OFFICECOPY_ -