18232 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FI CATION ,PERMIT NUMBER
BUILDING APPLICATION & PERMIT � O E�
AD DR Ess B Q^�M O 1 1 IQj - - C) J
L BUILDING-ELECTRICAL-PLUMBING-MECHANICAL A
OWNER'S y�f 10_o b0� PLAN CHECK VALIDATION
NA ZRO QTY. ELECTRIC PERMIT FEE
eotNTEaaIro h-I OUTLETS-SWITCHES-RECEP 10.00/1.00
NAM
uC.NO.Z r LIGHTING FIXTURES 10,00/1.00
CONADD IS 11 Rs . yV PPLIANCES-RESIDENTIAL 4.00
ADORES
Air)
OVE I PANELS 10.00 I x DATE OF APPLICATION
ARM ECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE .C.NO.
OR
NGIN
SIGNS TRANS. 3.00
a RCH. E G_ SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
iI - EMP.METER OR POLE INS. 20.00 PAM
APPucarvrs MOTORS SEE FEE SCH.
ADOR Ess
/- - SERVICE CHANGE 20.00 MAR 8.1 )991
o O LICENSIiU CONI'RA(.TORS DIiCIARATION ��yyy�
a 1 hereby affirm that I am licensed under provisions of Chapter 9 bil6ITA DATV__ ,
m < a (commencing with Section 7000)of Division 3 of the Business and BLDG.-- ECT.;�a PLO. • ;MECH.
F N i 1'nefesxions Cadl nd Ilccnse is"'(Ill tome and effec ❑
z 0 w- License{lass-FG.�_Lie.NumhcX1 xa
9 w Dart'af 1 o L4_I Cont.ctor' _
F L I
- a J n BU DIN PERMIT
ce Q w a OWNIi R-IIUILDIiR UECU\R TION r INFORMATION
soA MISC. REFER TO ORD
w ; LL m I hereby affirm that 1 am exempt from the Contractor's Lucerne VALuaTIO S/FT.
Ha Da Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE OQ
Code Any City ur CDlnty which requires B pcmut to const ruc1,alter, Q
4 0 improve,demolish.or repair any structure,prior to its Issuance,also ELEC.CONTE. LIC.NO. ELEC. ly�' q-y
0, requires the applicant for such permit to file a signed statement that TOTAL-�cella PERMIT TO
d w m he is licensed pursuant m the provisions of the Contractors License
Hz >
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Profctsions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
ce = $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
w. by any applicant nor a pemt0 suhjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.( 5.00
of not more than five hundred dollars(SS00)J:
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE '4.00 OCC.GROUP RES.UNITS
their cele compensation,will do the work,and the structure is not .
intended or offered for sale (Sec. 7044, Busines 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 does such work F IXTUR ES-PER TRAP - 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
'
himselforthrough [its ownemployers,providedthatsuch improve- GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
menu ore not intended or offered for sale.If,ed that s the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
impose
of Sala). INDUSTRIAL WASTE INTER. 30
builder will have the burden of proving that he did not build or im RES IND CON PB Onto
Prove Ibr p .00
❑ I,as owner of the properly,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contactors to constmet the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 A ESSURS WPARCEL 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 SPR IN KLERS-OVER 5IEA.) 1.00
contracts for such projects with a convaqui(s)licensed pursuant to
the Con tractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ um exempt undar Sec. ,B.6P.C.(or tllis WATER HEATER W/VENT 6.00
reason
Owner Dale WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO.
WORK It RS'COM PENSATION DECLARATION It WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to xllfinsur4 ZONING ENG.SITE NO.
or a certificate of Workers'Compenlice,or a certified
Copy thereof 3800,Lab.C.). si ii
Policy Na Company_ _
O ❑ Ccrlified copy is hcrtby f uniahcd FIRE SPRINK ENERGY T 74
z Z Cvtl I y is til ith 11 n inspection division.
O q/T)111cant•(j��� _ w MISC.- REFER TO ORD. Y E] N❑ Y ❑ N❑
� y C1iRT1 FICA 1,OI'E E:MPTION I OM WORKERSPERMIT ISSUANCE _ 10.00 FLOOD ZONE A.L.u.C.
W > COMPENSA'I ION INSURANCE PLG.CONTE. LIC,NO. PLG.'
d O (This.section need not he completed if the peris'for one I.G.
Y❑ N❑
mit Y ❑ IN E]
Z hundred dullars(SIBD)nr less.)
U O 1 certify that in the perli...moce ut the work tier which this per- OTY. MECHANICAL PERMIT FEE FEE.SUMMARY
IL F Crit is issued,I shall not employ any person in any manner so us to
U become subject to the W'orkeri Compensation Laws or California.
Q a Datc Appluant ALTER OR ADD TO MECH. 5.00 'BUILDING Ct 6,&0
} to
NOTICE TO APPLICANT: If,attar snaking this Certilicu¢•Cl Ex-
Z emplicn,you should become Subject to the Workers'Cern,nsation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IO,OWC.F.M.) 6.00 SEISMIC FEE
I hereby affion that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the perlonnxnce of the work Ior which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's
Lender's Address HEATI NG UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating Io building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorise representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection Empoai
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
operons, against IiabllA cs,jud .,ants, costs and expenses which PERMIT ISSUANCE 1000 CONST.TAX
may in any way See
agar said City i cone ucntt of the
r of this mit. MECH.CONT. LIC.NO. MECH.
gnTOTAL TOTAL
atu o A Ivan Con r 'tor tc
OFFICE COPY