12234 APFUCANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIF ION PER MIT NUMBER
APPLICATION & MIT
BUILDING
t
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 12234
PLAN CHECK VALIDATION
//� 2J QTY. ELECTRIC PERMIT FEE
JMONE
N E OUTLETS-SWITCHES-RECEP 10.00/1.00
.�� ; D LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S, NO.
DPPLIANCES-RESIDENTIAL 4.00
6ORess pp -
. . �a ONE PANELS 10.00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP) 20.00 '- PLAN CHECK FEE P.C.NO.
OR
ENGINEER _
LIC.NO. SIGNS TRANS. � 3.00
ADDRESS ENG, SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 PAW
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
Or`� 2lag
SERVICE CHANGE 20.00
0 o LICENSED CONTRACTORS DECLARATION
a v u I hereby affirm that I am licensed under provisions of Chapter 9
I" (commencing th Secllon 7000)of Division 3 of lh sl sand
¢e- BLDG. ELECT. PLG. MECH.
H M i Professions d ,s ry license is In full toter n f P.
z O,y, - License Class ms's Lic.Number El ED I E
4 u w Dafe Comore r
a : LI BUILDING PERMIT
¢ I[w u OWNER.BUILDER DECLAR 'PION INFORMATION
aO > MISC.- REFER TO ORD
X ; n.r 1 hereby ul'I'irm that I am exempt from the Contractor's License _
g Business and Professions VALUATION $/FT.
F u m a Law forthe City
following mason. requires
a, PERMIT ISSUANCE 10.00 s
m� Code: e,dem y demolish,
court pair any requiters permit prior
t O is issuance,
alter,
1 = < 0 improve,demolish,Or repair any slit lure,prior to its issuance,also L ONTR. LIC.N0. ELEC.
w m u requires the applicant for such permit to file a signed statement that TOTA PERMIT TO
lie is licensed pursuant to the provisions of the Contractor's License
iii Law(Chapter 9(commencing with Section 7000)ofDivision 3 of the
4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
er s-m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($5000.)'.
❑ 1,as..net of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their role compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
. property who builds or improves thereon;and who docs such work FIXTURES,PER TRAP 5.00 SO,FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
mems are not intended or offered for sale.if.however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ 1,as owner of the property,um exclusively contracting with El ❑ 0 ❑ ❑
licensed contractors to construct the project(Sec 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL 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(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,B.&P.C.for this
WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00ACC.DATE ACG FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to sell'-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Comps y_
O ❑ Certife cop her. y furn
ished/
Z Z ,�Certifie c I lid ih tie ci r' pjypfjt divisio FIRE SPRINK ENERGY TQ4
O Ap6Gcant ��'L MISC.- REFER TO ORD. Y [3 N� Y NE]
~ rn PERMIT ISSUANCE 10.00
LU - CIi R'I'I FICCOEPE E E PTI ONFROM WORKERS' FLOOD ZONE A.L.U.C.
W COMPIiNS T ON INSURANCIi PLG.CONTR. LIC.NO. PLG.
EL Z (This section need not a completed if the permit is For one TOTAL Y❑ N Y N
hundred dollars IS 100)or le
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
Ly, U mit is issued,I shall not employ any person in any manner so as to ,
become subject to the Workers'Compensation Laws of California.
W Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING '
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F. Z eruption,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 shall he deemed revoked. AIR HANDLING UNIT(TO 1Q000QF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IOAOOC.FM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT)' 5.00
the performance of the work for which this permit is issued(Sec MICROFILM
3097,CN.C.). I HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name tU1&Ayti, HEATING UNIT 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
• 1 certify Burr 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COW(3 H.P.Or 100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) to save, indemnify, and keep harmless the City of MISC.- REFER TO ORD.
Cuperti just liabilities,jud cots, costs and'expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may i an w a e again s id City in consequence of e
grant g Of e L MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signa a ol'Applican ntmetor Date.
OFFICE COPY