C 6626 AHFLICANT TO FILL IN INFORMATION WITHIN RED LINES — LIS" BALL POINT PEN ONLY
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APPLICATION & PERMITTE E S C BUILDING — ELECTRICAL—PLUMBING —MECHANICAL66
•
NAME 1 O 9 u{'. rrtx} { C ..•a ,tyt A,P _ PLAN CHECK VALIDATION
DE CARL PNONE rs.r,'o� HLECTRIC'FEfRMIT[IyJ /y�� SF
CONTRACTORS (EIF}"GAFF
NAME UTLETS-SWITCHES-RECEP 5.00/1.00
Drkv�rGS WODU ZULNO.rj$ LIGHTING FIXTUQ/1,00
RES '
:ONIPACTOP'S S,Q
ADORESS MSOX ED000 t41l PPLIANCES-RESIDENTIAL 4.00
FM-1409T CR Wily PRDNE COS - PANELS
ARCNITECT 5.00
OR DATE OF APPLICATION
ENGINEER SIGNS 6 QQ PLAN CHECK FEE P.C.NO.
LIc.ND. SIGNS TRANS. 3.00
ENGINE R ENG,
ADDRESS SPECIALCIRCUIT 5.00 PERMIT VALIDATION
AuvucgNrs ZIP EMP.METER OR POLE INS. 15.00
goOREss MOTORS SEE FEE SCH. -/
w ¢ i SERVICE CHANGE 10.00
i. O 4 LICENSYD CONTRACTORS DECLARATION
a i U haffirm that affirthat I am licensed antler provisions of Chapter 9
Q a (...numerical,wI",Section 70001 of Division 3 of the Business and ISSUANCE DATE
r w i Prnfessions Ca a,yIe1��y license is in full fu c a f•c
z
0- - Licenx Class_(`1�_Lic.Number L \ ELECT. PLG. MECH,
Hf Date y3.t_IS QContract., _ _ `• ❑ ❑ ❑
¢ Z
¢u¢, a r OWNER-BUILDER DECLARATION BUILDING'PERMITis^�.'
wa O a •^. ,"
3 Nirm that hereby uDI gm exempt
a from tile Contractor's License MISC.— REFER TO ORD ,a.!INPORMATIONpr?,R„�tir'(^,
O J Law for the following rcoson.(Sec.7031.5,Businessand Professions
my � Cade:Any city or county which re quires a permit to construcLalter, PERMIT ISSUANCE 600 VALUATION S/FT.
¢ ¢ ¢O improve,denmlish,or repair any structure,prior to its issuance,also ELEC.CONTR, LIC.N0.
a requires the applicant for such permit to file a signed statement that ETEC.
a w mu. he is licensed pursuant to The provisions of the Contrnclnh License TOTAL
rzQ Law(Chapter 91sommenung with Section 70001n1 Dins on3af the a PERMIT TO
Bminess and Professions Coder or that he is exempt Ihrrel'rom and GTY: v' 1 !e r .FEE
¢ I¢-m th ha.is for tli all gcd exmnpUnn Any violuYon nl Section]0315 ;-ci' '4PLUMBING FEflMIT'x r4giFEEt*,
s ; _ by any applicam f r a pemiiT suhleus the applicant roacivil penalty - ' +•r".r-' STORIES YPE C NSTR.
of not more than five.hundred dollars 155001.1: ALTER-DRAIN& VENT-WATER (EA.1 4.00
❑ I,as owner of The pmprny,ar my employees with wages as
their role compensation,will do the work,and the structure is not BACK FLOW PROTECT. DEVICE 2.00
itt TendeJ ar ollbreJ for sale (See. 7044, Business and Professions OCC,GROUP RES.UNITS
Code: The Contractor's License Luw does not apply to an owner of DRAINS-FLOOR,ROOF,AREA,COND. 4.00
• Pnlpeny who builds or improves thereon,and who does such work FIXTURES-PER TRAP
himself nr through hie awn employees,provided that such improve. 4.00
meats art'not intended or offered for sale.II,however,the bulldiGAS.EA.SYSTEM- SQ FT,FLOOR AREA TOTAL ACREAGE
or improvement is sold within one year of completion, the ownm 1 INCA OUTLETS 4,00
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4(EA.)
prove for purpose of sale.). 1.00 BUIL IN USE
n I,as owner of the property,am exclusive) INDUSTRIAL WASTE INTER. 20.00 RES IND PS Omer
licensed contractors to construct the y Contra with ❑ ❑ Q ❑
project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B.
and Pro fessiam Cock:The Contractor's L eense Law does not apply 5.00 OR
to in owner of property who builds or improves thereon,and who ASSESSS A CEL NO.
contacts for such PRijects with a contractor(sl licensed pursuant to LAWN SPRINKLERS-OVER 5(EA.) 1,00
the Contractor,License Law. SEWER-SANITARY-STORM EA.200ft/8.00
C, 1 alts exempt under Sec. ,B.&PC.for this TRACT NO. PARCEL NO.
reavm WATER HEATER W/VENT q
Owner Dale
WATER SYSTEM 4
00
WORKERS'COMPENSATION DECLARATION ACC.DATE ACG FILE NO.
1 herchy affirm that 1 have a Certificate of consent to sell:' WATER TREATING EQUIP. q-pQ
or a certificate of Workers'Compensgtjop ( ��e� Insure,
111\ p a certified
.copy thereof IS, A00,L'4C�� aF1'N'&� ZONING ENG.SITE NO.
Policy NRT�$_
ZO Cortilie tiy,� rch urnished, e-7 T
O y inspection Division.
Z JV- ` py n f d ///JMy FIRE SPgINK ENERGY T24
F- AnpBca �I{•P'/'�— MISC.- REFER TO ORD.
LU rn (TR F1171CATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE Y❑ N v El IN
W 0 COMPENSATION INSURANCE 6•� FLOOD ZONE A.L,U,C.
CL Q PLG CONTR LIC NO PLO
0 Z 1 fh-- coon need not he complete) if the permit is for one TOTAL v o
U O hunt dJDllars 141001 or less.) N v
N
1 certify that n the performance of the work for which this per. 1 3�' yA. SEl,u'7y"ta-'.+ �+hs,`a
LL U mIt issued,I shall not employ any person in any manner an as to GTS5'". MECN/11t11 PERM1fIT k"gp�B� �F_ $UMMARI�
O w beer,
me subject to the Workers'Compen ation Laws of Califomia
Date__, Applicant r
} y NOTICE 'DO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. q,QQ BUILDING
)— 2 emption,you+Imuld become subject to the Workers'Compensation gppLIA
provisions of the Labor Code, you must forthwith comply with 4.00 PLAN CHECK /- p
U such pr-visNCE ions or this permit shall be deemed revoked, AIR HANDLING UNIT(TO 10 lOwr 1
ABOGF.M) 3.00 FEE
CONST R UCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MCFM.) 5.00
I hereby affirm that there is a construction lending agency for SEISMIC FEE
The PerRxniance of the work for which this permit is issued(Sec. EXHAUST HOOD (WITH DUCT) 2.00
3097.micl-, .am HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50
1 Ceralfy that I have read This application and state that the above VENTILATION FAN ELECTRIC
.ormnatioo is correct I agree to comply with all City and county (SINGLE) 3,00
ordinances and state laws (elating TO building construction, and BOILER-CONP(J H.P,or 100,000 B.T.U.1 4.00 PLUMBING
herchy -,I -,ire epe,crumive, of this City to enter upon The
above "Im oned properly for inspection Purposes. BOILER-COMP(Over 100,000 BTU)SEE FEE SCH.
(We) 'gree to save, indemnify and keep harmless the City of MISC.- MECHANICAL
Cupcnin agumst liabilities,judgments, costs and expenses which REFER TO ORD.
may in y way ac nm gins[ s 'd City in consequence of the PERMIT ISSUANCE 3.00 CONST.TAX
gr I This per
MECH.CONT. LIC.NO. MECH.
O TOTAL
Signature of Applicant/'onlractor UnfeJ7- 'ITOIITALr'I¢i G
OFFICE COPY