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09959 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BILI LDI NG PROJECT I DENTI FICATION PERMIT NUMBER BUILDING APPLICATION & PERMIT 09959 ADD ES%Z ' BUILDING -ELECTRICAL-PLUMBING-MECHANICAL OWry R'S PLAN CHECK VALIDATION NA QTY. ELECTRIC PERMIT FEE NO /RsUTLETS-SWITCHES-RECEP 10.00/1.00 LIGHTING FIXTURES 10.00/1.00 CorvrR AOAPPLIANCES-RESIDENTIAL 4.00 DR � PANELS 10.00 DATE OF APPLICATION ARCHITECT/� PLAN CHECK FEE P.C.NO. on ('X PANELS IDV ER 200 AMP) 20.00 ENG�Ir�r�Fj� LIC.No. SIGNS TRANS. 3.00 ADD ARCH,QPOENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION A;ZJ ZIP TEMP. METER OR POLE INS. 20.001 APPLIC 'S MOTORS SEE FEE SCH. PAD A5 SERVICE CHANGE 20.00 NOV -71985 w o o D 5LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 ¢ u I hereby affirm that 1 tan licensed under provisions o(Chapter 9 JSAIDAIM an w G odi (commencing coil eci 001 of Division 3 of the usjness and B D L MECH. r w z Professions Cod 'cense is in full Z0 O m- License Clas Li um - o w F Date Piructor a m I BUILDING PERMIT ¢ ¢ w ¢ OWNER-BUILDER DECLARATION INFORMATION A O a " MISC.- REFER TO ORD X g; ¢ I hereby affirm that 1 am exempt Isom the Contractors License in VALUATION S/FT. FLLoa Law forthe following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 Code:Any city or county which requires a permit to construct,alter, n�C� ac R¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. -O ac requires the applicant for such permit to file a signed statement that TOTAL P MIT TO a w m be is licensed pursuant to the provisions of the Contractor's License H z r Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe ¢ Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE ¢ r c the basis for the alleged exemption.Any violation of Section 7031.5 1 STORIES PYFE CONSTR. u ; m by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER IEA.) 5.00 of not more than five hundred dollars($500).): ❑ 1,as owner of the property,or my employees with wages as BACK F LOW 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 (See. 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 thereon,and who does such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE • himself or through his own employees,provided that such immove- Himselfects a nor intended his or employeeffered for sale.provided that s the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00 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 of proving that he did not build or im- RES INDPB Omarprove for purpose of sale.. INDUSTRIAL WASTE INTER. 30.00 ❑ 1,as owner of the property,am exclusively Contracting with ❑ [IC ❑ ❑ licensed contractors to Construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSOR P RCEL NO. and Professions Code:The Contractor's License Law does not apply to as owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00 contracts for such projects with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO. the Contract LicenLaw ❑ I Tempi unse der Sec.. .B.&P.C.for Hits WATER HEATER W/VENT 6.00 reason 410 Owne Date WATER SYSTEM 5.00 ACC.GATE ACC.FILE NO. WORKF-RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 1 hereby affirm that 1 have a certificate of consent to self-insure, ZONING or a certific of Workers'Compenmtion In rangy or certified ENG.SITE NO. co Q Certified copy is hereby famished. FIRE SPRINK ENERGY T-24 Z O ❑ Certified copy is fled with the city inspection division. MISC.- REFER TO ORD. E) ❑ C] ❑ Applicant Y N Y N W_ N CERTIFICATEOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. IL 0 (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑ ::) Z hundred dollars($1001 or less. L) O I cerufy t m the perlbrmance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY LL P mit is is 1 shall not employ any person in any manner so as to U beconniWect to the Workers'Compensation Laws of California. W Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING } m NOTICE TO APPLICANT: If,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 with FEE / U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10p00C.F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE I hereby affirm I at ere is a construction leading agency for EXHAUST HOOD(WITH DUCT) 5.00 the performance of y(e work for which this permit is issued(See. MICROFILM 3097,Cw C.), U//) HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name HEATING UNIT(OVER 100,000 B.T.U.0.50 ELECTRIC Lender's Addrc 1 terrify that I 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 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 above-mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cope o a inst liabilities,ju I its,costs and expenses which CONST.TAX may I an a cme a airs Id City in corse uence of the PERMIT ISSUANCE 10.00 gr g MECH.CONT. LIC.NO. MECH. ZTOTAL TOTAL Signa[ re ofA Iicanr/Contractor Date OFFICE COPY