6786 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
E G PROJECTIDENTIFICATION gppLICATION & PERMIT_ 6786
r BUILDING -ELECTRICAL-PLUMBING-MECHANICAL_ 1 Iy{jY(r j tt .. 1 �( f 'j f y r7 ;i 'e{ PLAN CHECK VALIDATION
ME
if �� �,r/PHONEDTY �'dy lUTLETS-SWITCHES-AECEP 5.00/1.00
NAME /
,1 Lrc.NO f/f/iI ILIGHTING FIXTURES 5.00/1.00
CONTRACTOR', PPLI ANCES-RESIDENTIAL 4.00
7
{ PiRONEr�I��/ /}j:j PANELS 5.00 DATE OF APPLICATION
ARCHITECT 1 SIGNS 6.00 PLAN CHECK FEE P.C.NO.
Gfl
ENGINEER
LIC.No. ISIGNS TRANS. 3.00
ARCH.oR ENG'
ADORES, SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
/� IIP EMP.METER OR POLE INS. 15.00
APPLICANT'S _ l 'r /// ' (-. MOTORS SEE FEE SCH. -(XJ"�'-��`�
ADo u i z L. C�.
SERVICE CHANGE 10.00
002
0o LICENSE CONTRACTORS DECLARATION
X u w 1 hereby.11.... that 1 ant licensed under pruvi'Im"of Chapter 9 ISSUANCE DATE
„aN (, mmencmg with Section 7000)of Division 3 of the Basin e s and BLDG. ELECT. PLG. MEC7.
2 Z O I-werviats Code,'u_nd.n,-lic.�roe is in full forcu yqd s ❑ ❑ ❑ 'y-T
_•o Limnx Clio l Lic.Nwnher t �'�y 7NTI
Uate Cnntnctor
o r r• ''
a rBUILDING P,ERMIi ,
Ic rt w a OWNIiR-IIUILUIiR UECLA RATIO Iy, yHyt�1;INFORMATION ,
Wo a m I hereby affirm that 1 am exempt front the Contractor's License MISC.- REFER TO ORD a
3 u Y' p VALUATION f/FT.
Fu04 Law fur the following«awn.(See.7031.5,Buainessand Prol'cssions PERMIT ISSUANCE 6.00
Code'.Any city or county which reyuires a permit toconstrncl,alley
rt Q¢ � improve,demoloh,orrepairany structure,prior to its issuance,also ELEC.CONTH. LIC.NO. ELEC.
ry KOLL r ywn,the applicant fmrsuch permit io Irle a Mgned aal ul'nt that TOTAL PERMIT TO
Q m v, lie Is licensed pursuant to the provisions o1 the Ce mr. Tor Liecn
r z r
Law(Chapter 9(commencing with Sutton 7000) HDlvi Ion3.1the
'� s f1 t'. * o�,la,� { t ✓�
a r o the tim6 anand
Poullessc ev Cade).,that he
isac.t of.lfic,cfn7n mot OTV_ alb it k jl P. PiLUMBING.PERMIT/' y,rM1'n al. tFEE �
xZIMHa h'' A t �' STORIES TYPE CONSTR.
cam by any applicant for a permit subjects the applicant tua civil penalty ALTER-DRAIN -WATER (EA.) 4.00
_
of nut inure than five hundred dollars(Y500).)'.
❑ I,as owner of the property,or nsy employees with wages as BACKFLOW PROTECT. DEV ICE 2.00 OCC.DROUP RES.UNITS
sole co opcnvtion,will do the work,and the structure is net
intended a of I'Yr y(IC(Scc. 7044, Business and Ptofin,ions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:'rbc Contractor' It nse Law duo out apply to an owner of
properly who huildso taIt rill lhec'nn,and who does such work FIXTURES-PER TRAP 4.00 SO,FT.FLOOR AREA TOTAL ACREAGE
�• himself or Drmugl)Itis aJD' mphoyccs,Provided Omi such improve-
EA.SYSTEM-1INC.4OUTLETS 4.00
mentsare not i, d rug civil for sale.it,however,the building GAS-
tar impnsvemctsl rs hr),thin ane year ul completion,The uwner GAS-EASYSTEM-OVER 4 (EA) 100 BUILDING USE
builder will have the burden of proving that he did not build or im . . .
RES IND CON PB Omar
prove for purpose a :d
' e.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractor, to construct the prnyet(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or unproves Thereat,and who LAWN SPRINKLERS-OV ER 5 IEA.) 1.00
cmurums fur,bell pruiects with a cootoicu (0li xn,ed pursuant to
The Contriew'a License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ Iame.cm,l under Sec. ,B.&P.C.far Ibis WATER HEATER W/VENT 4.00
reason
Owner Dare WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK I:RS'COM PENSA'I'DON DITLARATION WATER TREATING EQUIP. 4.00
1 hereby allarn that 1 have a c,lifl.ule ol'cwmm to oil=insum' ZONING ENG.SITE NO.
r a certificate 1 Workers'Cou9mnsaliun[,I'll nee, r nil is
UBta'' 11 b..
BW.lab.Cl
Iic�NofLi�l�!II�CumpunY /`/// •(/
0 `❑',LqrEtied iPYOi hefebY;lumiilrvr/ LI FIRE SPRINK ENERGY TR24
Z Z �.y�Cz(line,�' 1 J5�AG 0 tY n,pn'lion divi,ion.I
O AppliCanf -t��L t'i� �L- ��y MISC. REFER TO ORD. Y❑ N❑ Y ❑ N❑
H m PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.C.
Cr � CER'1'IFIC' TEOFIAEMPI'ION FROM WORKERS'
LU - OPENSAT10N INSURANCE PLG.CON TH. LIC.NO. PLG,
CL Z (This section I ed nut be completed d the permit u fur one TOTAL Y❑ N❑ Y ❑ N❑
U O hundredcertify
eti yollars IS da,inlitt of or perllorm nee of The work for which the pc i q l u )t
LL F rml rs issued,I shall nor em lo�m1y enppn m un manner w as to qTV +.tjj t��L r NIECHAI41CAL•PERMh]�hAs�' • 6
U Rome sublecl to WorlePs' mpnsarun Wwsuf Calil'omia. vd•= Ys.W Y'. �(. '_r' : i"7! '+. .1:
0 i Date AppliJanT- ALTER OR ADD TO MECH. q•00 BUILDING
} N NOTICE TO API ICA [[ II,a ter making This Certificate rel ER-
F Z emPtion,you should ht ryb eel to the Wurknri Compensation APPLIANCE 4.00 PLAN CHECK
provisions of The" r,Code, You ...it forthwith comply with FEE
(J such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10000GF.M.) 3.00
CONSTRUCrION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00CF.M.) 5.00 SEISMIC FEE
I hereby affirm That there is 4 construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the
3097 eGv.C.)nce Of The work 'or which this permit is issued(Sec. MICROFILM
UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ^l _ ELECTRIC
I certify that I have F6141 hiy' p icalion arid'Eite That The above VENTILATION FAN (SINGLE) ,�,� 3.00 Lb
urlonna lion is curreal. I ajr t comply with all city and county PLUMBING
Urdlmmcev and stale lows rehab g to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00
�••1. out rize representatives of this city to enter .,,on the
u .Perry lot inspection purposes. BOILER-COMP lover IOO,000 RTUI SEE FEE SCN. MECHANICAL
Wvc-men El tcJ pr / L
(We o V m vry indcnud
.k, F q. IY anJ keep hurndc,s the City of MISC.- REFER TO ORD.
Cupc• w Iia dine',l J'ments, costs and expenses which PERMIT ISSUANCE ✓ 3.00 7.7 CONST.TAX
ii - e aR'- s said CiIY in conxyuen<e OI The
ant lig I' r t 'r /`�� jF� MECH.CONT. LIC.NO. MECH. `. ," !_I„
i ' iY x) TOTgL Kr;•,,:(lj� .,.s
m
y/6 /"1/11
' Signature a Pplicant Conttac tar UaL--
��t-I-
OFFICE COPY
APPLICANT TO FILL'IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
BU LDING PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILOING• APPLICATION & PERMIT
AUURE55
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 6786
NAMER '' PLAN CHECK VALIDATION
nn . QTwV!k-t,,'IP�--N- ya:ELECTRIC P.EFiM1T }t r !P'FEE
C'(i PHONE - €.-s •x a - a A 'f
CONTRACTORS .
rvnme OUTLETS-SWITCHES-RECEP 5.00/1.00
LIC.Rai
o LIGHTING FIXTURES 5.00/1:00 '
CONTRAGTGRs PPLIANCES-RESIDENTIAL 4.00 - -
A oR 11
P{IDNE '7 PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6,00 PLAN CHECK FEE P.C.NO. .
OR
ENGINEER -
, - LIC.No. - SIGNS TRANS. 3.00
AARCH OR DDRESS ENG SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
IPrrEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
0 ss
Ao
SERVICE CHANGE 10.00
Foo LICIiNSIi)CONTRACTORS DECLARATION /// /�/
u w 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
a,< (<nn... i,ing with Section 7000)of Division 3 of the Busim, and BLDG. ELECT. PLG. MEC .
H N_z Professions Cnd n else is in full for ❑ ❑ - ❑
z o u,- Livense Clas Lic.Number
o m lou Uatc Contractor
a m E, - 'BUIIDING`PERMIT
IS¢ NE -BUILDER DECLARATIO C
is ;acu a- I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD r '"51NFO,RNIATI'ON
aU .. o¢ Law for the following reason.IS".7031.5,Rusinessand Professions pERM1T ISSUANCE 6.00 VALUATION bjFT.
Cade:Any city or county which reyuiresa permit to construct,alter,
IS rt¢o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- O S, rttluiru[the applicant for such Permit to file a signed statement that TOTAL PERMITTO
a w m he is licensed pursuant to the provisions of the Contractor's License
I- z>
Law(Chapter 9(ccmmencing with Section 7000)of Division 3 ofthe - $�
F 4 o Business and Professions Code)or that he is exempt Therefrom and QTN:�' " p,>' PLUMBING'P,ERMIT, t�. 'i FEE'''.'
M1- the basis for lite alleged a xempl ion.Any violation ofSection 7031.5 -•�' w STORIES TYPE CONSTR.
a3 � by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER (EA.):4.00
of not more than five hundred dollars(E500L)
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 200
their sole compensation,will do the work,and the structure is not . OCC.GROUP RES.UNITS
intendeJ or offered f r yyLLIIe co. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Cada'rhe Contractor Ifidense Law docs not apply to on owner of
property who bit Idso I eves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself"r Lb rang is mPloyees,Provided That such improve- -
mcnts�renmin d fend for sale.if,however,the building . GAS-EA:SYSTEM-I1NC.40UTLETS 4.00
or improvem rs ithin one year of completion,the owner- GAS-.EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder Will have DIc bu en of proving that he did not build or im- RES IND CON PB Other
prove for purpose of wle.). INDUSTRIAL WASTE INTER. 20.00
. ❑ 1,as owner of the property,am exclusively contracting with 0 ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs 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 contowil fs)licensed punuanl to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/B.00 - TRACT NO, PARCEL NO.
❑ Ianlcxcmpluodcr Sec: ,B.&P.C.for this
reason WATER HEATER W/VENT 4.00
Owner Dale WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORK ERS'COMPBNSATION DECLARATION WATER TREATING EQUIP. 4.00
1 herby aIf..A I],at 1 have a certificate of consent to self-insure, ZONING ENG.SITE NO.
ora certificate of Workers'Compexi:tn ¢e,ion Inr a ecrtific
onspany
�- ❑ CIt
he y urnisle . FIRE SPRINK ENERGY T24
Z Zslyinspection division.OAppiaMISC- REFER TO ORD. rNr❑ No
i OP IiXIiMPPION I°ROMWORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU PIiNSATION INSURANCIPLG.CONTR. LIC.NO. PLG. y� N� v� N�
(L O /Thus not be Completed if the Permit is fill one TOTAL
Z) Z hundred dollars IS 100)or less)
U O . I certify that in the perform nee of it work for which this per My,. 7MECHANIC�AL PERMIT"v F,EE ( FEE SUMMARY
LL F roll rs issued,I shall not cmplo an6 pers n in any manner so as to by? o s»
O m become subject to the Workers o tp ns ion Laws of Callforma `1• +
0- Date APPL( m ' ALTER OR ADD TO MECH, 4.00 BUILDING
} tn' NOTICE TO APPLICA If.li!nr making this Certificate of Ex-
F- 2 emption,you should s teel to the Workem'Compcnsatiolt APPLIANCE 4.00 PLAN CHECK
provrslons of th or o c, ou must forthwith comply with FEE
V such provisions or this per it Shall be deemed revoked, AIR HANDLING UNIT(TO 10,000GF.M.) 3.00
CONS'rRUCfION LENDING AGENCY AIR HANDLING UNIT(OVER IQOOOOEM.) 5.00 SEISMIC FEE
1 herebyaffirm'that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work or which this permit is issued(Sec. MICROFILM
3007,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's Address ELECTRIC
I certify that 1 haves hi p icalion and stale that the shove VENTILATION FAN (SINGLE) 3.00
inlonnalion is corn . I a r I comply with all city and county PLUMBING
ordinances and store lows relwi g to building construction,-and BOILER-COMP(3 H.P.or 100,0008.T.U.1 4.00
hereby out rite representatives "1' Ibis city to eller upon the BOILER-COMP (Over 100,000BTUISEE FEESCN, MECHANICAL
above-nrcn t ,d property for inspection purposes. /-
(We to sav indcm y sad keep harmless the City of MISC.- REFER TO ORD.
Cape i, s Iia hies,j it moots, Costs and expenses which CONST.TAX
ROY n a s said•City in emaluenc of the PERMIT ISSUANCE 3.00 -
mnt rg f MECH.CONT. LIC.NO. ME�TC4AH,,�L. ,
TO�� •:TOTAL`
Signature Ill i Applicant nntruc or Date
OFFICE COPY