7134 ,l APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
i"•j' y"
'BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
AN`HESS APPLICATION
PERMIT APPLICATION & PE
5;.
L7- -l '�LL BUILDING ELECTRICAL-PLUMBING-MECHANICAL
7134
M1 ow .q's �,�S
N I�a1' �1 ysle} RI/ Ik 4 IJ SxM'{+�o710Na'{' An A'¢'j�Ir;' . PLAN CHECK VALIDATION
OTYr t�'10h14t��t ELECTRIC PE " n wFEE+Sc'17,
rilese
1 � L PHorvE i f.. �J A{ui a,
ONIRAC Oq5
la
NA UTLETS-SWITCHES-RECEP 5.00/1.00/
11C.NO LIGHTING FIXTURES 5.00/1.00
•.r,
1-.5.
AOOREss PPLIANCES-RESIDENTIAL 4.00
l *t/��%� PHON' 5.001
1{ AgcgnecT '�� PANELSDATE OF APPLICATION
on SIGNS 6,00 PLAN CHECK FEE P.C.NO.
i INGINEEH
LIc.nO. SIGNS TRANS. 3,00
AHCH.Ofl FNG.
AooHgss SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
'I APPLICANT'$
Aoogess MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
-/
•
Dili
F D oLI('ENSEU Cl1N'fRACPURS UE['LARA'I'ION J
a u u 1 hereby illi....that I and licensed under Provision,of Chapn'r 9
n <- (colnou'nelog will Section 7000)of Division 3 or the tlminws and ISSUANCE DATE
Prolessions CoJ�yJ Lcense is in full force slid rf'e BLDG. ELECT. PLG. MECH.
z i w License lass yi {r__Lie.Neither
0,,i Date Conlmclor- ham'
¢w OWNIi R-BUILDER DECLARATION yvl;•�; BUILDINGP.ERMIT ""`$.�(�'yr�g
w; A N I hereby atlirm that I am exempt from the Canlraclor%License MISC.- REFER TO OR d.!''FS!.I NFORMATION1111
F a. o a Law Jot tile following u,a,on.(Sec 7031.5,Businessand l'ruh'esaium PERMIT ISSUANCE VALUATION .SIFT.
f ">f Code:Any city.,county which requires❑permit m construct,alter, 6.00
¢ G ¢ O improve,Jemoliall,or repair any Slmetere,prior to its issaance,'also ELEC.CONTR. LIC.NO.
O¢ su
require,the applicant for ch pennil to IIIc a signed statement that ELEC.
TOTAL
A le m¢ he Is licensed pursuar,l In the P, ,nouns of lie Cou
nlr' lor's License PERMIT TO
ri >
Law(Chapter 9(Lommenemg with Section 7000)of Division 3 of ther
f i o Business and Prufesaona Code)or mal he is exinmt therefrom uW a>:(i 7T ' "PLUMBING PERMIT'^}4,{�'3'y s �L--d
Me buses ler he alleged exnnp Run Any viulul ion Of Section 7031 5 I ( r FEE`i�r
s 3 h an a lu'anl for a r '' - - )'_ •r�'.v l} }} nhyh i _fw</,pi STORIES TYPE CONSTR.
Y Y pp perncddoll..s S500).fisunlmacivil penally
fruit mare than foftilendreperlyi rInye).}: ALTER-DRAIN& VENT-WATER (EA.) 4.00
❑ Las ower of the will dozy,or my enlpluyees with wage>as BACK FLOW PROTECT. DEVICE
intended
sole r offered
I., will(S the work,unit the structure is out 2.00 OCC.GROUP RES.UNITS
Code: dor ofl'creJ f"ser sole (Sec. 7044, Busincas and Profession, DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Conlnctor's License Law does not apply to an Owner of
property who builds or improves lhercun,and who docs such work FIXTURES-PER TRAP
( Y hi nwir.r Through his own employees,Provided Nut such iuIPnOe4.00
- SO.FT.FLOOR AREA TOTAL ACREAGE
rents are not iolenlcd or offered ler safe however,elm building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within enc year al'completion, the.wnt,-
builder will have the burden of proving Ihuf he did not build or ire- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
prove f1.ors owner of sole.). INDUSTRIALWASTE INTER. RES NO CON PB Omer
❑ d as owner of the property,he project
vcly contracting with 20.00 ❑ ❑ ❑ ❑ ❑
licensed contractorshit lu construct the project(Sec. does 1 Dwindle LAWN SPRINKLERS- 1 INC 5 V.B.
and Prulessi.ns Code:The Contractor's License Law docs nal apply 5.00 ASSESSORS PARCEL NO,
to an owner of property who builds Or improves fiction,and who LAWN SPRINKLERS-OVER 5(EA.) 1,00
contracts for suvh projects with a cuntraCtags)licensed pursuant to
the Contract.,',License Law. SEWER-SANITARY-STORM EA.200([/6.00
❑ Iron exengn under Sec. ,B.&P.C.for this TRACT NO, PARCEL NO.
reason WATER HEATER W/VEN 4.00
Owner Dale
WATER SYSTEM 4,00 ACC.GATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING E I
1 thereby 4.00
Y of I Inn Ihat I have a cert utio a of donne..,.,sclF,til io.•, .. ... ....
ser a tarsil iaale of Workeri Compenwtion Insurance,or a eenified 20NING ENG.SITE N0.
copy IhcreoflSec.3500,I.ab.CJ4 � S
Pnlicy Na Cu cicb _Gla=As'y4+Vy
Z ❑ Cc Nil icd is hercb m d. p� O
Boo
Z 2 C'ertll op i, kfV the city inspection division. FIRE SPRINK ENERGY TYA
cc T
ppliwn _� e MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ NC]
[ . cAl OF Exh fPT10 BOM WORKERS' PERMIT ISSUANCE 6.00
W J C'OMPENSAT'ION INSURANCE FLOOD ZONE A1.U.C.
d O ., YLG.CONTO. LIC.NO. PLG. rnrf
This w bon need not be Lampleicd if the pennil is for no TOTAL aX, f� Y N� Y N�
0ZO hundred dollt,0100)or less)
I Certify that in the performance of the work for wilull[])is per-
LL
er n ti n
LL f nut is I'>ueJ I ]IIJII 1101 ding Ly any person III ally I1Wliner>0 J!1. DTV i,,, i f MECHANICAL PERMITI IIiT,yt i.FEE + m 1 e%1 jl.,FEE SUMMARY❑- q.r1 e
U fav ._. ......
O nee subject to the Workeri C'umpenvlion Laws of CalilOmia. I"{I ' "/` 1 ru �'; `
1 Dat. ICAN-1:
ALTER OR ADD TO MECH. 4,00 BUILDING
} In NOTICE TU AI'I'LICAN'I: If,alter making this Certil Teale of lix-
�- Z emplion,you should become subject to the Wurken'Comp u,,Iiun APPLIANCE
U 4.00
provisions of the Labor Code, you must I'ofthm
wilh comply with PLAN CHECK such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=1C.F.NL) 3.00 FEE
CONS'fRUC17ON LENDING AGENCY AIR HANDLING UNIT(OVER I0,000C.F.M.) 5.00 SEISMIC FEE
I hereby iffinn thus life. is a con,lrueli.n lending agency for EXHAUST HOOD IW ITH DUCT) 2.00
the perk...ounce of tile work for wbielf fill,permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender'sAddress H EATI NG UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I cattily thus I have read this xpplicufion and stet,that the ubnae VENTILATION FAN (SINGLE) 3.00
I,Ainformation is correct. I agree to comply with all city and county PLUMBING
ordinances and ❑fate laws relating to building construction. and BOILER-OOMP(3 H.P.or 100,000 B.T.U.) 4.00
� hereby uullbloo, n•prex•n Wlives of This city to enter..,on lie
ahwve-nention,J property for inyecliun purposes. 11 LER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
Cup'" agree to sive. indlou and k •p hunnlev the City of MISC.- REFER TO ORD.
cnin. against liabilities d nncul seats and espenus which
Flay in any ' 'a, •ai 1 seefly in ansequco« of tie PERMIT ISSUANCE 3.00 CONST.TAX
Stunting Illi).
MECH.CONT. LIC.NO. MECH.
TOTAL
.igna ih iCmuwn Da.• - ,--TOTAL.}
OFFICE COPY
APPLIkA'ANT TO FILL IN INFORMATION WITHIN, RED LINES - USE BALL POINT PEN ONLY
s BUI LD1 NG PROJECT IDENTIFICATION PERMIT NUMBER
UILDING APPLICATION & PERMIT
' ADDRESS 'ILDING
OV T ( /IGL BUILDING- ELECTRICAL-PLUMBING-MECHANICAL _ 7134
Tf
y PLAN CHECK VALIDATION'
d 'A QThV,E ° *{'i ' ,EI:ECTRIC`PkERMITx z1p+P., yf
PHON
NOANTRA/c ORS UTLETS'-SWITCHES-RECEP 5.00/1.00
.Le .T �J'G uc.NO, LIGHTING FIXTURES 5,00/1.00
C.orvraacroR's APPLIANCES'-RESIDENTIAL 4.00
r_ ADpRE55 }t'le(,(/
/- f/ PNON' p(,(/
PANELS 5.00 DATE OF APPLICATION
ARRCHITECT SIGNS 6.� PLAN CHECK FEE - P.C.NO.
ENGINEER
Llc.No. SIGNSTRANS. 3.00 -
ADDRESS ENG. PERMIT CIRCUIT - 5.00 PERMIT VALIDgTION
zm EMP.METER OR POLE INS. - 15.00
APPLICANrr
ADDDRESSDRESS MOTORS SEE FEE,SCH.
SERVICE CHANGE 10.00
e o O LICENSED CONTRACTORS DECLARATION o • -
a U U I hereby affirm that 1 an,licensed under provisions of Chapler 9 ISSUANCE DATE
a <m (commencing with Section 7081)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H N PmfessimLc Cnd a license is in full force a d e ❑ ❑ ❑
z O m, License/(lass- oi� Lia Nwnhcr /_jam}'
y_J
Date-('�- -'�-Y-Cmdommr,
Y¢ a OWNER-BUILDER DECLARA HON I n, BUIL-'DINCib-PaERM1T
a d u t ' °INFORMATION
'K ;u r 'I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD "
LL O¢ Law for the following reason.(Sec.703 1.5,Business and ProfessionsVALUgTION S/FT.
L - Code:Any city or county which requires permit tocuns'trucL alter, PERMIT ISSUANCE fi.00
oimprove,demolish,or repair any struclure,prior m its issuance,also ELEC.OONTR. LIC.N0. ELEC.
S, requires the applicant for such permit to file a signed Statement that TOTAL PERMIT TO
n w m he is licensed pursuant to the provisions of the Contractor's License
•F i
Low(Chapter 9(commencingwith Section 700(bfDivision 3 of lire
i o Business and Professions Code)or that he is exempt therefrom an&
PLUMBING PERMIT PEE"*
X s-$ the basis for the alleged exemption.Any violation of Section 7031.5 , STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty
ofnot more than five lmndred dollare(f500L): ALTER
-DRAIN&VENT-WATER (EA.) 4.00
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00
their sold compensation,will do the work,and the stpslure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4,00
Code:The Contractor's License Law does not apply to an owner of _
r. property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.0014
SQ FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees•provided that such improve- -
mends are not intended or offered for sale.IL however,the buildingGAS-EA.SYSTEM-l1NC.40UTLETS 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 that he did not build or int
prove for purpose of stile.), INDUSTRIAL WASTE INTER. RES IND CON PB Omer
❑ I,as owner of the property,am exclusively contracting with 20.00 0 ❑ ❑ El E a
.licensed c.mmriors plconsUrct the project(Ser.7044,Business LAWN•SPRINKLERS-1INC 5 V.B. 5.00 'ASSESSORS PARCEL NO,
and Professions Code:The Contractors.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 Suelu projects With a conlructons)licensed pursumH to
Ilse CmInsu, ar's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,B.&P.C.for this WATER HEATER W/VEN 4.00 '
reason
Owner Date WATER SYSTEM 4.00 Ace.DATE qec.FILE NO.
WORK ERS'COMPENSA'TION DECLARATION WATER TREATING E I1 4.00
' I hereby affirm that I hove a ceirdiculu of consent to rel Ginsdm.
ora certificate of Workers'Compensation Insumace,sura certified ZONING ENG.SITE NO.
a,py ihcreuf(Scu.3800,Lab.C.).
Policy No. Company-� �yIs/,t '
O ❑ Cerlified NS fetch nt d. FIRE SPRINK ENERGY T-z4
z Z Cerhr, up is the city inspection division. -
O pplictn, MISC.- REFER TO ORD, YE] N YE] N�
~ T PERMIT ISSUANCE 6,00
LU C. CA OPI I IPTIO RANGE,WORKERS' FLOOD zorvE A.L.u.c.
W COMPENSATION INSURANCE,the 'PLG.CONTR. LIC.NO. PLG. Y E] N Y o
0 Z (This section need not be completed if the permit is for e' TOTAL GCeC N
hundred dollars(5100)performance
S . -a-Pyam,
U O I cart lfy that in the performance u1'the work for which this per 'QTVR- MECHANICA4PERMIT*`'•- ;;FEE;4 '; wFEE}SUMM,ARY
IL mut is Issued,I shall not employ any person in any manner so as to ., '
U W become subject to the Workers'Compensation Laws of California. - "$ ,
n Dam Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} W NO'T'ICE TO'APPLICANT: If,after making this Certificate of Ex-
emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1Q000C,F.NL) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 5.00 SEISMIC FEE
I hereby affirm TWO them I, a conspuction lending ageneyfor EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is.lssued(Sec. - MICROFILM
3097,Civ.C.L - HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT 100,000 B.T.U.)7.50
Lender's Name - ELECTRIC
.10I certify that l have read this application and stale[list the above VENTILATION FAN (SINGLE) 3.00
information is correct. 1 agree to comply with all city and county PLUMBING pOZ�
ordinances and state laws relaling'to building conslnmtion,.and BOILER-COMPI3 H.P.Or 100,000 B.T.U.1 4.00, K
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
c
'Lcuper&badies
e) agree In save, indoor 'fy and Ip ep harmless the City of MISC: REFER TO ORD.
tino against liad men ! osis and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
cruo ai t sa' .I ly in conseyucnce of theit, MECH.CONT. LIC.NO. MECH.
TOTAL
TOTAL
t/Contract Data
OFFICE COPY