11012?j'sf('. '`'`• APPLICANT TO FILL IN INFORMATION WITHIN RED LINES --USE BALL POINT PEN ONLY -- - -
" BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
r 1101 Z
� ➢�•e aV`ILOING APPLICATION & PERMIT
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{ O —/I (V �+ BUILDING— ELECTRICAL—PLUMBING—MECHANICAL
OWNLR'S - PLAN CHECK VALIDATION
NAM //II CITY. -,ELECTRIC PERMIT 'FEE
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( �'d — PHONE - , I . IT .,.:: .. -nI•
CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
LIC.NO / / LIGHTING FIXTURES 10.00/1.00
CONTRACTORS p'PIP, 14LT� PPLIANCES-RESIDENTIAL 4.00
ADOREss x�
9�W SUI
I-C I PHONE a PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. 5,00 PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADORESS
' SERVICE CHANGE 20,00 /� �AL�r✓�y—/
" Woo LICENSED CONTRACT ORS DECLARATION
<u U I hereby affirm that 1 am licensed under pror'isimu of Chapter 9 ISSUANCE DATE
N Qz La N (commencing wfill Section 7800)of Division 3 of IIIc Business.,to BLDG, ELECT. PLC. MECH.
'r z Professions Code,and my license is in full force and it•cl. ❑
oi=O License Lie Numty�r, -1 ��) ❑ ❑
4 m r j Dalo Conlmelof v�E�
LE, OWNER-BUILDER DECLARATIONINFORMATION
, I;tr
o a " MISC.– REFER TO ORD INFORMATION r +'
w ; LL n I hereby al flan that I am exempt from the Contractor's License VALUATION f/FT.
LO< Law for the folluevingreuwn.(Scc.7031.5,Businessandl'rotessions PERMIT ISSUANCE 10.00
H w m Cade:Any city or county which requires a permit to Construct,alto,
su¢ FO improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
CLL (equlres IIIL'appllCant tOr tach perinll N ole d slgnell sldtQllelll Ihat TOTAL PERMIT TO
K
$ he is licensed pursuant to the provisions of the Contractor's License
rzr LLw(Chapter 9(commencing with Section 7000int Diction 3 office
< Business and Professions Code)or chat he is exempt Iherclrom and CITY'. PLUMBING PERMIT .'fi + '.,FEE -
LIEr o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i ; m by any applicant l'urapenIII subjects file applicant tuacivil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred Jollan(S500L)'.
❑ I,as owner of the properly,or my employees with wages as BACK F LOW PROTEC6 REIWE 4.00 OCC.GROUP RES.UNITS
their woe cooppensatiun,will do IIIc work,and like structure is nut
intended or offered for sale(Sec. 7044, Business and Pmfcssions DRAINS-FLOOR,Roo ,A COND. 5.00
Code:*file Contractor's License Law does not apply to am owner of
properly who builds or improves thereon,and who dues such work F IXTUR ES-PE .1 . 5.00 SD.FT.FLOOR AREA rOTAL ACREAGE
-,.• himself re noting,his own employees, le.h,Ip Imre such implove-
mentsarenolimendad oncrinoforealroided Ito Imildio, GAS-EA.SVSTE IN ,O,TLETS 6,00
or improvement is sold within one year of completion,the owner GAS-EA.SV STE E 4 ZOO BUILDING USE
builder will have the burden of ace n,that he did not build or int- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WA 1 T 30.00
❑ I,as owner of the property,am exclusively contracting with
licensed contractors m construct the Projem ISCC.7044, Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00Oct ASSESSORS PARCEL NO.
an J Professiom Code:The Commclol's License Law dues nut apply
to an owner of properly who builds nr Inspmves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
Contracts for such projects with a contructorls)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ l ant exempt under Sec.—.ILMIC.for this WATER.HEATER W/VENT 6.00
reasin
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC,FILE NO,
WORK ERS'COMPFNSATION DECLARAT ION WATER TREATING EQUIP. 5.00
1 hereby ufl irm that I have a ceeificzt of chosen)Iu srlGiroure• ZONING ENG.SITE NO.
or a certifwate of Worker,' m
Compensation Iuranec,or a certil icJ
copy thereof(Sec.3800,Lab C.). 41 s •df- 3— 0440
I'ol(cy NCumPunY�Va—T��- �Y
O Jp Certified Copy is hereby furnished. LJIII fl4 RIL., FIRE SPRINK ENERGY T]q
Z Z ❑ Certll'y���Opy is IiIcJ h the tY uuPecliun .iv nl.
O Applicant�.'1. a� 110r`>1,r ( x J t�' MISC.- REFER TO ORD, r ❑ ry❑ v ❑ rv❑
x w CERTIFICATE OF EXBMI'TION FROM WORKERS' PERMIT ISSUANCE 10.00 U �' FLOODZONE A.L.u.c.
LU > COMPENSATION INSURANCE PLG.CONTII. LIC.NO. PLG. / L IN C] Y ❑ N❑
IL O floes section need'nut be complcicd if ,t permit is for one TOTAL L!
0 Z hundred dollars IS 100)or It,,.)
U O 1 certify that in the perforooice of the work for which this per- QTY. MECHANICAL PERMIT L FEE FEE SUMMARY,
LL k- mit is issued.I shall not employ any person in any manner so as to PERMIT, -'
U become subject to the Workc,s Crmpcmatium Laws of California.
O w Date ApplicantALTER OR ADD TO MECH. 500 BUILDING
} 'w NOTICE,TO APPLICANT: If,after making tons Ceeil'icare of Es-
. .
,F Z empth m,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shell be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
_ CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=11C.F.M.) 6.00 SEISMIC FEE
I hereby affect that there is a construction ICnding agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work(or which this permit is issued ISec. MICROFILM
3097,Civ CA HEATING UNIT(TO 100,000 B.T.U.) 8.00
LendName
rider's NHEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Name ELECTRIC
1 certify than I have read this applicmiun and state Icl the above VENTILATION FAN (SINGLE) 4.00
inlornjxllin is correct.1 agree to Comply with all city and county PLUMBING (p
ordinances and state laws relaling to building construction, and BOILER•COMP 13 H.P.or 100,000 B.T.U.) 6.00
hereby authorize repremnulives of this city l0 enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
ubovrmenlioncd property for inspection purposes.
(We) agree to s,oc. indemnify and ks•Cp hared... III,Cipof MISC.- REFER TO ORD.
Cupenuso against Ilahilltles,judpulnms, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
granting of this pecten. MECH.CONT. LIC.NO. MECH.
TOTALTOTAL
t
'•namrc o(Applieam/Cmvmer Date
FFICE OCOM