6784 APPLICANT TO FILL IN-INFORMATION WITHIN•RED LINES -'USE BALL POINT PEN ONLY
BU LPERMITNUMBER
PROJECT IDENTIFICATION APPLICATION & PERMIT
nOiwlNr. 6784
:ADDRESS r
BUILDING-ELECTRICAL-.PLUMBING-MECHANICAL
Owry EH'S 4 $, y ,aw` her sy# 'x PLAN CHECK VALIDATION
NAME
QTY' v k N:''EI:ECTRICiP" I1 1 ^ ",-
a`
COONTR•ACTORS UTLETS-SWITCHES-RECEP 5.00/100
TIC,NO. LIGHTING FIXTURES 5.00/1.00
CONTRACTOR's
ADDRESSDRESSAPPLIANCES-RESIDENTIAL 4.00
A
PANELS - 5.00 DATE OF APPLICATION
ARRCHITECT SIGNS, 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER-
LIC.NO. SIGNS TRANS. - 3.00
ADDRESS ENG. - SPECIAL CIRCUIT 5.00 PERMIT VALIDATION'
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
-A OREss ,r
G//U'/1 ISERVICE CHANGE 110.00
02 LICENSED CONTRACTORS DECLARATION
a v I hereby affirm flat I an licensed under provisions of Chapter 9 ISSUANCE DATE
ta "' (commencing with Section 7000)of Division 3 of the Business and
D y BLDG. ELECT. PLG. MECH.
D Z F 2 Professions Code yI a se is in full for
License E] r_1 11i
o m - Class
r
P
w r w Date-21�_O�Cnnlractor oClof 41
BUILDING`PERMIT
¢ 1 OWNER-BUILDER DECLARATION * • "-,i a+
a o a O ' - `IN,EORMA•Tj10Na
w g a-y .I hereby aft HR that I ars exempt from the Contractor's License MISC.- REFER TO ORD --
0- 04 Lawlor lbr the following reason.(Sec.7031.5.&Isinessandl'rofessions PERMIT ISSUANCE 6:00 VAwATION $/FT.
Code:Any city or county which requires permit to construct,alter,
¢ Q improve,demolish,or repair any slruclu prior to its issuance,Who ELEC.CONTR. LIC.NO., ELEC.
O ¢ regwres the applicant Ira such permit to de a signed statement ilial TOTAL
u w m" he Is licensed pursuant to the pn as f the Contmcmr's License
RMIT To
F i i Law(Chapter 9 H ommcncl wi h cU i 7000)of UmslOn 3 of the s "" >„ a:'
3 ¢ o Business and Professions Co ) t e is exempt therefrom and CITY '' PLUMBING PERMIT FEE'
¢ I-$ the oasis for the alleged e m m Ry vmlatl n hf Section 7031 5 STORIE TYPE CONSTR.
a3 � by any applicant foray Its j st he applicant fee civJpenalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than Five h d II.(E E ).
❑ I,as owner of 11 c or my employees with wages as BACK F LOW PROTECT. DEVICE 2.00 OCC.GROUP RES,UNITS
their sole compen R,wI do the work,and the structure is not
intended or offered for sal (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code The Contractor's License law docs not apply to an owner of
property who builds or improves thereon,and who doessuch work FIXTURES-PER TRAP 4.00 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such Improve-
mcuts are not intended or Offered for sale.ll'.however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4,00
'ru improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDI G USE
In der will have the burden of proving that he did not build or im-
proveforpurposeofsale.). INDUSTRIALWASTE INTER. 20.00 RES IND C PB Omar
- y❑ 1,as owner Of the property,am exclusively contracting with ElEl ❑ ElIicenseJ contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESS 5PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EAJ 1.00
contracts for such project[with a contractions)licensed pursuant t0 SEWER-SANITARYEA.200ft/5.00
the Contractors License Law.. TRACT NO. PARCEL NO.
❑ 'I inn exempt tinder Sec..,R.&P.C.for this WATER HEATER WIVENT 4.00
reason
` Owner - Date WATER SYSTEM - - 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate orcumenl to self-insure,
or a certificate of Workers' an motion Insurance,or a certified ZONING ENG.SITE NO.
copy I - rl goo,La . L
_ Policy Nn._ [['o -
0 �❑".�.Certified p iso byfurnished. FIRE SPRINK ENERGY T2
Z Z ,S( Certit., n y filed with thF
e city inspection division. -
O A�nnllcunt MISC.- REFER TO ORD.
pY❑ N❑ ' Y❑ N[_]G PERMIT ISSUANCE 6.00
UJ - CIiRTIPICCOJ' EXIiMPTIFROM WORKERS' PERMIT ZONE A.L.U.c.
W �_ COMPEE N NSATIOINSURANCE PLG.CONTR. LIC.NO. PLG.
I CI (This section need not be completed if the permit is for one TOTAL 'Y❑ No . Y❑ N❑
U O hundred dollars IS 100)or less.) y, e
I certify that in the performance of the work for which this per (: �' NIC 9 FEE SUMMARY
'QTY. n NIC E M - FEE
LL U mit is issued,I shall not employ any person in any manner s0 as to p,rPa� i a e Y r
become subject to the Workers'Compensation Laws of California. 'moi F - L1•
0 a Date - App icunt ALTER OR ADD TO MECH. q-00 �. BUILDING
} N NOTICE:TO APPLI T: ,THer making this Certificate of Ex-
I- Z crop ion.you should bec s je t to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK '
provisions of the L or a must forthwith comply with FEE '
U such provisions or t ' cr i a e deemed revoked. AIR HANDLING UNIT(TO 10,00DGF.M.) 3.00
` CON ON LENDING AGENCY AIR HANDLING UNIT(OVER 10=C,F.M.) 5.00 SEISMIC FEE
I hereby - th t there 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.L HEATING UNIT(TO 100,000 B.T.U.) 4.00
lender's Name HEATING UNIT(OVER 100,000 B.T.U.17.50
Lender's Address ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) -3.00
information is correct. I agree to comply with all city and county PLUMBING
oNiwnces and state laws relating to building construction, and BOILER-DOW(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives or this city to enter upon the
abuveanentioned property for inspection purposes. BOILER-COMP Inver 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) a e to suve indemnify and keep harmless the City of MISC.- REFER TO ORD.
q.nt
urns Iia hies,j mems, costs and expenses which .pERM1T ISSUANCE 3.00 CONST.TAX
h i¢ a agars said City in consequence of the h 1 MECH.CONT. LIC.NO.r
TOTA
- 3
Signature 'ApTOTAL
plicantlContractor Date -
OFFICE COPY