15938 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -: USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENT[FI CATION .PERMIT NUMBER
BUILDINGAPPLICATION & PERMIT [(� /� Q
Ao s1O D BUILDING - ELECTRICAL-PLUMBING-MECHANICAL - � 9 3 8
OWNER'5 - PLAN CHECK VALIDATION
" ME MIA4^ STV. "/ , ELECTRIC PERMIT ?-�' FEE;
[A4'1 xPMONE
CONTRACTOR'S
NAME UTLETS-SWITCHES•RECEP 10.00/1.00 Ma
LIGHTING FIXTURES 10.00/1.00
ADDRESS tuns Fre X119' APPLIANCES•RESIDENTIAL 4.00
NTRC "It �a
Sao PHONE( / f
G -t4 PANELS 10.00 SATE OFAPPLICATION
ARCHITECT P�,AN,pHC P.C.NO.
OR PANELS (OVER 200 AMP) 20.00 AIyA y_
ENGINEER th1le MM
LIC.No. SIGNS TRANS. 3.00
S S
ADDREENG. Y, ?ERMIT VALIDATION
ADD R OR SPECIAL CIRCUIT 5.00 ,-7tYlf pYli gWssa
zip TEMP.METER OR POLE INS. 20.00 _ 2 �
ADDRESS
MOTORS SEE FEE SCH.
APPLICANT'S
1�)T yv)p SERVICE CHANGE UORD
Woo LICENSED CONTRACTORS DECLARATION
<u w' I�hemby afOrm that I am licensed under provisions of Chapter 9 ISSUANCE DATE .
w< (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT, PLG. MECH.
r n i Professions Code,and my license is in full force and effect. ❑ 131=1❑
oi=D License Class Lic.Number
_ Date' ' ' Contractor
a sa s � ✓•• •�, - BUILDING PERMIT,,-,?,,A,
¢ ¢w�;• :�,. -.,;, OWNER-BUILDER DECLARATION ,: »t INFORMATION .'ys(3:%i'
X o A t- " 1 hereby-.
ereby affuiri-that I em exempt from the Contractor's License MISC.-: • - REFER TOu y VALUATION S/FT. no a Law for the following reason.(Sec.7031.5,Business and ProfessionsNJ PERMIT ISSUANCE
Code:Any city or manly which requires a permit toconstruct,eller,
C cc<cic improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
wo w^ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
-, he is licensed pursuant to the provisions of the Contractor's License
i' Law(Che ter 9(commencin with Section 7000 of Division 3 of the �''C2 r`1"t`i
o 1 Business and Professions Code)or that he is exempt therefrom and STV. r`y PLUMBING PERMIT Wrrr 4U FEES-
¢ r 8- the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant ton civil penally ALTER-DRAIN -WATER (EA.15.00
of not more than five hundred dollars(SSGO).):
0-L'as owner of the,property.or my employees with wages as ->, BACK FLOW PROTECT.DEVICE 4.00 OCD.GROUP RES.UNITS
theii sole compensation,will do the work,and the structure is not
intended or offered for Sale(Sec. 7044, Business and Professions ,r
DRAINS-FLOOR,ROOF,AREA,COND- 5.00
Code:The h builds
o oLicense Lew does not apply to an owner of property who builds or improves thereon,and who does such work ? FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
-(' menus re through de own employees,provided that such improve-
orimprovemenotntissoldoroffered inone year sale.
however,the the o ner- GAS•EA.SYSTEM-11NC.4OUTLETS 6.00
r fk, or improvement'is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) - 2.00 BUILDING USE
builder will have the burden '.proving that he did not build or im- RES IND CON PS Otbar
prove for purpose of sale.). a'.,; ` tr INDUSTRIAL WASTE INTER. 30.00 ❑ El ❑ ❑ 0
-
El- 1,es owner of the propeRY.em exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
End 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 IEA.) 1.00 -
contracts for such projects with a contractons)licensed pursuant to II
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACTNO. PARCEL NO. !.
. 0 I am exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 6.00 f
reason
Owner Date WATER SYSTEM 5.00 `
ACC.DATE ACC FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent to self-insure, ZONING ENG.SITE NO.
of a certificate of Workers Compensation Insurance,or a certified
copy thereof(Sec.3600,Lab.C.). -
Policy No. 0Company
O Iris Csnlfie oy is hereby furnished: FIRE SPANK ENERGYT 24
Z 2� 71E Cenifie py is filed w' the city inspection division. MISC- REFER TO ORD.
O Applicant - Y N Y [3 No
~ PERMIT ISSUANCE 10.00
H - CERTIFICATE OF ' EMPTION FROM WORKERS' FLOODZONE A.L.U.C.
SL > _ COMPE ATION INSURANCE PLG.CONTE. LIC.NO. PLG,
d C (This section need not be,completed if the permit is for one TOTAL Y IN Y❑ N[3
� Z hundred dollars(S 100)or less.) ^ -
U O 1 certify that in the performance of the work for which this per, CITY.'• MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mil is issued,I shall not employ any person in any manner so as to
become subject to the Workers Compensation Laws or California.
i Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} WNOTICE TO APPLICANT: Ir,after making this Certificate of Ex-
F - emption,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply withFEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10.000C.F.NL) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,00011FM.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the 3097 performance of the work far which This permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
v
Lender's Name
Lender's Address HEATING UNIT(OV ER 100,000 B.T.U.19.50 ELECTRIC
I certify that l have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
--
information u correct.I agree to comply with all city and county PLUMBING
ordinances and state s relating to building construction, and BOILER-COMP 13 H.P.or 100,0008.T.U.) 6.00
hereby out r..c re re nlaliyts of city to enter upon the BOILER-COMP lover 100,000 BTU)SEE FEE SCH. MECHANICAL
above men ned p p ly fo spe ton purposes.
(We) ee to vl. df and keep harmless the Caf MISC.- REFER TO ORD.
uperlin ga' B bi i j rights, costs and Zscs..yh' h CONST.TAX
ay in y cc r aid City in conscef he PERMIT ISSUANCE 10,00
ranting it., 11 ECHE CONT. LIC.NO. MECH. -
TOTAL TOTAL . IaAW
S at a pp Icanl o c or- [e
OFFICE COPY