7011L:
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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION
APPLICATION & PERMIT
UILDING — ELECTRICAL— PLUMBING — MECHANICAL
PERMIT NUMBER
7 011
FIUNING
ADDRESS ) 08 /IS S'%3✓&r aa-
.+G
IOWNER'a
X6'9' + N�-,'
11cF.S1
PLAN CHECK VALIDATION
NAME
�`— �r O' YCc� C7Q,
G: VGNV PHONF
.ByLETRICVERMI�jj����
} Kkx nY.lr��TiF\itY.Y'i hI'SC�ST(;.yr"%�i5. <t.,l .r
CONTRACTOR a
UTLETS- SWITCHES -RECEP 5.00/1.00
1. o,
LIGHTING FIXTURES 5.00/1.00
A NAEs ORs
APPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
PHONE
PATE OF APPLICATION
A CHIT ! 1
OR LYJ
ENGINE R
uc.NO.
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADD a°Ss eeG.
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 15.00
ZIP -
APPLICANT
DR
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
Y/�46S
LIC17NSLD CON TRACTORS DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9
Icommencing with Section MOM of Division 3 of the Business and
Professions Code. and my license is in full force and effect.
License Class Lie. Number
ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
❑ ❑ ❑ ❑
Dale Cmunie'tor
OWNER -BUILDER DFCLARA TION
1 hereby affirm that 1 am exempt from the Contractor's License
Law for lire following reason.(Sec. 7031.5, Businessand Professions
Code: Any cilyorcounly which requiresa permit to construct. alter,
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9(commencing with Section 7000) of Division 3 of the
Business and Professmns Code) or that he Is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031 $
by any applicanten
for a permit sable cts the applicant too civil palty
at not more than five hundred dollars (S500).):
L
fa4 Ojp R111111�
'
MISC. — REFER TO ORD
PERMIT ISSUANCE__
6'�
VALUATION
�r,,C. h.4�''`
A •v v V
E/FT.
ELEG CONTR. UNO.
TOTAL
PERMIT
( TO
K
STORIES TYPE CONSTR.
OTK: - ,� VLUM81N0 VERMIT 4�><•3'#`� ht,,,, �'P.��EE.
,. �'r'9 m 4,1•'x; T•� r- r{+t y Yrif `'=:R4'•A•'j
ALTER -DRAIN & VENT -WATER (EA.)4.00
❑ 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
ROOF, AREA, COND. 4.00
intended or offered for sale (Sec. 7044, Business and ProfessionsDRAINS-FLOOR,
Code: The Contractor's License Law does riot apply to an owner of
FIXTURES - PER TRAP 4.00
GAS - EA. SYSTEM -1 INC.4 OUTLETS 4,00
properly who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
mentsarenotintendedorofferedforsale. If, however, the building
SQ FT. FLOOR AREA
TOTAL ACREAGE
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im-
prove for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 1.00
BUILDING USE
RES IND CON PB Other
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply
to on owner of property who builds or improves thereon. and who
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1,00
ASSESSORS PARCEL NO.
contracts for such projects with a contractions) licensed pursuant to
the Comracmr's License Law.
rCatV❑ l am exempt under See.., B.&PC. for this
11
SEWER -SANITARY -STORM EA. 200108.00
TRACT NO.
PARCEL NO.
WATER HEATER 111 4,00
owner Date
WATER SYSTEM 4.00
ACC. DATE
ACL, FILE NO,
WORKERSCOMPENSATION DECLARATION
WATER TREATING EQUIP. 4.00
1 hereby Ar..R that I have a certificate of consent to self -insure,
ZONING
ENG. SITE NO.
or o certificate of Work • ' Compensation Insurance, or a certified
.ropy thereof ISe<.
Policy No.❑
Certil icd❑ Certill ohe city inspection divisFIRE
Applicant_ 1101
SPRINK
Y ❑ N❑
ENERGY T�24
Y ❑ NO
MISC. - REFER TO ORD.
1 :RTIE-XEMPTION FROM WORKERS'
SATION INSURANCE
IThis sectio ne of he completed if the permit is for one
PERMIT ISSUANCE 6.00
FLOOD ZONE
y❑ N❑
A.L.U. C.
Y❑ N❑
PLG. CONTR. LIC. NO.
PLG
TOTAL
11 ndred G IS l or less.)
I certify that in the performance of the work for which this per
nit n issued, I shall not employ any person in any manner so at 10
he,ome,ma,11 to the Workers'Compenmtion Lawsof California.
Date Applicant
- -
OTY 4 - MECHANICAL:PERMIT '•-+: r^FEE sT
6 A q. �., F 1
�;cr c +1•'
.4Y
_ FEE
BUILDING
�O4_0
ALTER OR•ADD TO MECH. 4.00
NOTICF. TO APPLICANT: If, after making this Certificate of Ex.
APPLIANCE 4.00
AIR HANDLING UNIT ITO 10000 C.F.M.) 3.00
PLAN CHECK
FEE
enlptian, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked
AIR HANDLING UNITIOVER 10 C.F.M.)5.00
SEISMIC FEE
%Q
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for
the performance til' the work lot which this permit is issued ISec.
3097, Civ.C.L
EXHAUST HOOD WITH DUCT) 2.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address
H EATING UNIT (OVER 100,000 B.T.U.17.50
ELECTRIC
VENTILATION FAN (SINGLE) 3,00
I certify that i have read this application and state that the above
information n correct I agree to comply with all city and county
ordinances and state laws -luting to building construction, and
BOILER -COMP 13 H.P. Or 100,000 B.T.U.) 4.00
PLUMBING
hereby aulhori eprnse aHves or,
f this city to enter upon the
above -menti d e or inspection purposes.
BOILER -COMP IOver, 100,000 BTU) SEE FEE SCH.
MECHANICAL
(Wel 'fy and keep harmless the City of
MISC. - REFER TO ORD.
Cutter' g s, gments, costs and expenses which
may in a ainst said City in consequence of the
CONST. TAX
PERMIT ISSUANCE 3.00
gr ng
MECH. CONT. LIC. NO.
MECH.
TOTAL'a'.tTOTAL'`.
14
JP/ eZ0
S' pplicant/Contractor I Dale'
OFFICE COPY