12904 APPL-WoANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBS
roue°e"ss 20863 STBT/� ^�S APPLICATION & PERMIT ^ O4 A
.SNIeTE rGO Cr.CPGrX-T-�^'v BUILDING- GELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME OPV,S" QTY. ELECTRIC PERMIT FEE
NTR /OS PHONE
•y � /A- UTLETS-SWITCHES-RECEP 10.00/1.00
/ -A//N$C(L,q /4/2
LIc.No"3 3 LIGHTING FIXTURES 10.00/1.00
CONTRACTORS ,e�uw C f 7- APPLIANCES-RESIDENTIAL 4.00
AP,o �y�.� �g�,1JrP E �(+�/�/� PANELS 10,00 DATE OF APPLICATION
onCHITECiPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
Ofl
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH OR ENG' SPECIAL CIRCUIT 5.66 PERMIT VALIDATION
ADDRESS
EMP.METER OR POLE INS. 20.00 /� //!] �L ,✓
APPLICANTS 21P MOTORS SEE FEE SCH.
Ao REss 1
V � Q,�'iJ f✓ SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION d
¢u I hereby affirm that I am licensed under provisions of Chapter9 ISSUANCE DATE
yaw (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H H i Professions Code�a= tl 'cense is in full f alld f?� ❑ ❑ ❑
2 o L Licenu CI Lic. ractmNumbY �
O to H w Date Contractor
¢ r s BUILDING PERMIT
¢ ¢ 4 OWNER-BUILDER DECLARATION
K0. MISC.- REFER TO ORD INFORMATION.
wg LL r 1 hereby affirm Ihm I am exempt from the Contractor's License
.: o Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city or county which requires permit to construct,alter,
SE a¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
u O u requires the applicant for such permit 10 file a signed statement that TOTAL PERMIT T�
X 2 w he is licensed pursuant to the provisions Got the Contractor's License
pis Law(Chapter 9(commencing with Section 7000)of Division 3 of the LZ'
Q Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ H the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant toa civil penally ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).7:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
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[hereon,and who does such work FIXTURES-PER TRAP 5.06 SO.FT.FLOOR AREA TOTALACREAGE
• me!dsre net hrough
ownemployees,for sale.
If,edthmsuch improve- GAS-EA.SYSTEM-I 6.00
himself
are not intended or emplo for supe.If,however,the building
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 PS Omer
Cl I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed Contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-I 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 In
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
❑ I am exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Data WATER SYSTEM 5.00
ACC.DATE ACC.FILE N0.
WORKERS'COMPF-NSATION DECLARATION - WATER TREATING EQUIP, 5.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING
or a certificate of Workers'Compenption I mrance,or/a certified ENG.SITE N0�
P
rApplicant
ee,78 o Paab.Y.).// . 6 , .
Q ertili cc ppyishere Uy,f mshcd. FIRE SPRINK ENERGY T-24
Z ertifi copy 's a ith city inspection division. MISC.- REFER TO ORD.
p Y❑ N❑ Y ❑ N❑
~ w - - PERMIT ISSUANCE 10.00 FL000 zoNE A.L.0 c.
X : TIN TEO (EMPTION FROM WORKERS'
W 2: COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
d Q (This section need not be completed if the permit is for one TOTAL Y❑ ,N❑ Y❑ N❑
Z hundred dollars(S100)or less,) .,
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY '
LL H mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
i Date: Applicant ALTER OR ADD TO MECH. 5.0 BUILDING
} m NOTICE TO APPLICANT: If,after making this Certificate of lix-
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK _
provisions of the Labor Code, you must forthwith comply with FEE
such provisions or this permit shall be deemed revoked AIR HANDLING UNI C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNI 0 ER10006 EM.16.00 SEISMICFEE
1 hereby affirm that there is a construction lending agency for EXHAUST HO I 5,00
the performance of the work for which this permit is issued(Sec. HEATING UNI 1 ,000 B.T.U.) 6.00 MICROFILM
3097,Civ.CJ.
Lender's Name HEATING UNIT( E .U.19.50
Lender's Address ELECTRIC
1 certify that I hove read this application ami state that the above VENTILATION (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-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL /v
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cuperfln most liabilit'ex,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX !• " •5
may i way � against said City in consequence of the d
granli this puluft MECH.CONT. LIC.NO. MECH.
C� _�7-9 TOTAL `5� TOTAL
gnatur fA i nt/Contractor Date
OFFICE COPY /
t.