17389 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
:.BWI LOI G.PROJECT IDENTIFICATION PERMIT NUMBER)
aU,Ln,NG ' APPLICATION & PERMIT 738(1
ADDRESS o��J•F I ( 0 BUILDING- ELECTRICAL-PLUMBING-MECHANICAL L 8 JJ
V
OWNER �[/�p �p�y PLAN CHECK VALIDATION
NAME �1 �7 DTV. ELECTRIC PERMIT FEE
,(J, PHONE
CONTRACTOR'S 1.
NrfJJ OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No. LIGHTING FIXTURES 10.00/1.00
CONT CTO 'S
ADDRESS S.Q,17L„2, Sa(soro APPLIANCES-RESIDENTIAL 4.00 .
PHONE PANELS 10.00 DATE OF APPLICATION'-
ARCHITECT
OR PANELS (OVER 200 AMP) 20,00 - PLAN CHECK FEE P.C.NO.
O
• ENGINEER - .
LIC.NO. SIGNS TRANS. 3.00
ADDRESS END. SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 1 I
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS C 2�
1Q SERVICE CHANGE 20,00 (,(�
00 LICENSED CONTRACTORS DECLARATION V e(t,W0� _-P-i
Q u U I hembymaencing ffirm Ihul 1 a,n licensctl ulldCr pnrvisous of Cmptcr 9 ISSUANCE DATE
(comwith Section 7000)of Division 3 of the Business and
¢ vdi MAR BLDG. ELECT. PLG. MECH.
F o 2 License Cla Code,and my license is in full foie and effect ❑ ❑ ❑
o i w License Class Lic,Number
F m F J Uulc Cnnlruclor �s,
rc se ¢ a OWNER-BUILDER DECLARA'I']ON coy Of C BUILDING PERMIT
M a u - INFORMATION
A,
g 1;; 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION
FUN J Law for the following mason.(See.7031.5.Businessand Professions PERMIT ISSUANCE 10.00 $/FT.
Code:Any city or county which requires a permit to construct,alter,
v: 2¢ D improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIQ NO. ELEC. (7 V
a wD¢ requires the applicant for such permit IU file n signed statement that TOTAL PERMIT TO/_
$ he is licensed pursuant to the provisions of the Contractor's License (
H r Law(Chapter 9(commencing with Section 7000)cf Division 3ofthe (\
io Business and Professions Code)or thin he is exempt therefrom and CITY. PLUMBING PERMIT FEE �C� IE-
ac
B
ac H $ the basis for the alleged exemption.Any violation of Section 7031.5' STORIES TYPE CONSTR.
A. by any applicant for a permit subjects the applicant to a civil penalty gLTER•DflA1N& VENT•WATER (EA.) 5.00
of not more than five Ionated dollars($500).):
❑ 1,as owner of.the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
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 r through
builds or improve employees,
pr and who docs improve.work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employers,provided that such improve-
omeats rimprrynot mentendedwithin offered
onefor
yearsale.If,however,[liebuildingow Eng GAS-EA.SYSTEM-11NC.4OUTLETS 6.00 3'(�' (� 'r•.
or improvement is sob within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 1
builder will have the burden of proving thin he did not build or im- BUILDING USE
prove 1for,aso nee of sale.). INDUSTRIAL WASTE INTER. 30,00 RES IND CON Pe Deter
❑ d as owner of the property,he exclusively contracting with ❑ ❑ ❑- ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. -
and Professions Code:The Contractor's License r th docs not apply
to an owner apody who huilds ar improves thereon,and whot to LAWN SPRINKLERS-OVER 5(EA.) 1.00
cuntrac trot projects with a contrncmrl sl licensed pursuant to
If, actor icense law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
H I a exe Ito on ce ,B.&P.0 for this WATER HEATER W/VENT 6.00
reason � - ,
Own., Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
0 'ERS'COMPI?NS ON IiC1,ARATION - WATER TREATING EQUIP. 5.00
1 hereby aff ret that I have a eL lificate cfconsenl to self-insum, ZONING ENG.SITE NO.
or a certifieme of Workers'Compensation Insurance,or a certified
copy thereof(See.3800,Lah.C.L
Policy ert Company
❑ Certified copy isherebyfiled furnished, FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is tiled with the city inspection division. MISC.- REFER TO ORD.
O Applicant V❑ N❑ Y❑ N❑
~ rn PERMIT ISSUANCE 10,00
LU - CE RTIFICATEPF EXEMPTION RAN WORKERS' FLOOD ZONE a.l.0 c.
W � COMPI?NSATION INSURANCE PLG.CONTR, LIC.N0, PLG.
CL 0 ('This section need not he m Ictad if the Penult Is for one TOTAL Y❑ N❑. Y❑ N
hundred dollars($100)or les.
U O I certify that in the pert non •nl'Glu wor to hich this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
} F mil t - sl anot Wen lay ny lie TV g in m most as to
O w her 1 �tyTYa!syrc the Work c t of C main.
CL Dat Applican _ BUILDING ((qq
rn NOT T P ICAN'I': If,an-
Makin this Cent Erato of p-x, ALTER OR ADD TO MECH. 5.00 (l lJ
F ? emption,you should become subject to the Workers' ampensition APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisionsor this permit shall be deemed revoked. AIR HANDLING UNIT(TO IOAMCF.M.) 4.00
CONSTRUCTION L17NDING AGENCY AIR HANDLING UNIT(OVER 10=C.FM.) 6.00 SEISMIC FEE
I hereby aff" that Detre is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the perl'orman e f jh work for w ich this permi s Issued(Sec. MICROFILM
3097,Civ.C.). - HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name ne. HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address !1 -eM/L
I certify that I have'.rI a Ibis application itd all c that the above VENTILATION FAN (SINGLE) 4.00
ordinances isstatecorrect. 1 agree to cu mply with all city and county PLUMBING
ordinances and state laws relating In building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
Retch Ihorize representatives of this city to enter upon the BOILER-COMP IOver 1181,000 BTU)BEE FEE SCH. MECHANICAL
ab me boned property for inspection'"P' s.
(We) gree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
upertil against "'its,judgments,sonamen", costs and expenses which pERM1T ISSUANCE 10.00 CONST.TAX '
may in any wa accrue against said City in Consequence o the
rami ofth' a Y. - MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL �f
i n luteol'Applicant/Co frac Dale
OFFICE COPY