18795 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
v BUILDING PROJECT I DENTIFICATI ON -LCo PERMITNUMBER
SoL.7NG 1/A-
APPLICATION & PERMIT O�]n[
ADDRESS o 1 a7�J
y 'D 2. - BUILDING - ELECTRICAL-PLUMBING-MECHANICAL Ia
OWNER'S (4YOI PLAN CHECK VALIDATION
"AME `-'1 11- 4_- QTY. ELECTRIC PERMIT FEE
CCPT�A NE
CorvTRAc*ry+y ov9L ,�� OUTLETS-SWITCHES- 10.00/1.00 -gD ly1
NAME .✓ rr � h-A J
(- _4UU LIC.NO. 5076 LIGHTING FIXTURES 10.00/1.00 '
CONTRACTOR S / APPLIANCES-RESIDENTIA4.00 ,p9
ADDRESS '/'r / ,/'w/,.
13 F/,5F/,5 6 1 PHONE 4n49kl;l PANELS 10.00 ! ,Sp DATE OF APPLICATION
ORRCHITECT.ja�M Iz r(S PANELS (OVER 200 AMP) 20.00 PLANCHECK FEE D.C.NO.
ENGINEER `I
GAIL L4v1 LIC,No.L 6SIGNS TRANS. 3.00
ARCH,OR ENG. SPECIAL CIRCUIT S,OQ PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00 t J Z-
APPUCANTs MOTORS - SEE FEE SCH. Gr
ADDRESS
SERVICE CHANGE 10 n 20.00
w o o LICENSED CON"I'RACI'ORS DECLARATION ✓ `r �-} �,�p/��//
< eo'. I hereby uff irm that I um licensed under provisions of Chapter 9 0, ISSUANCE DATE `r
w<w (commencing with Section 7000)of Division 3 of the Business and - - - - --�- - BLDG. ELECT. PLG. MECH.
r 0 z Protessions Code, 1 my license is Ni
full lore,and vffec.
z 02 - License Class Li c.NumI ` O LJ-}-
< y o Dale - ' Contractor f rl PF 0 mall IRO
¢ ¢w a OWNER-BUILDER DECLARATION BUILDING PERMIT
U REFER TO ORD INFORMATION
w :u m I hereby affirm that I am exempt from the Contractors License MISC.- VALUATION p $/FT.
u_o J Law for the following reason.(Sea 7031.5,Business and Professions PERMIT ISSUANCE 10.00
r - Code:Any city orcounty which requiresa permit to construct,alter,
¢ ¢ 3 O improve,demolish,or repair any structure,prior to its isspance,also ELEC.CONTE. LIC.NO' ELEC. '7�I
O ¢ requires the applicant for arch permit to file a signed statement that TOTAL- ,]p PERMIT TO
a m a- he is licensed pursuant to the provisions of the Contractor's License
La La Law(Chapter 9(commeacingwilli Section 70001uf Divislon3ofthe �1/•.. �V:
- a Business and Professions Code)or that he is exempt therefrom and QTY- PLUMBING PERMIT FEE
¢ IOD the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE ON$TR.
dam_ by any applicant for a permit subjects the applicant o a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00 D
of not more than five hundred dollars(55001.):
❑ I,as owner al the property,or Pry employees with wages as BACK FLOW 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,AR EA,COND. 5.00
Code:'Phe Contractor's License Law does not apply to in owner ofQ O
property who builds or improves thereon,and who does suds work Z FIXTURES-PER TRAP 5.00 So.IT.FLOOR AREA TOTAL ACREAGE
h himself or through his own employees.provided that such improve GAS-EA.SYSTEM-11NC.4 OUTLETS 6.00
mems are not intended oroffered
on for sale If,however,the building
or improvement is roll within one year of that
he did o t the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not buil)or hit-- RES IND CON PB Onber
prove 1for.aso nee ofsale.).the.). - INDUSTRIAL WASTE INTER. 30.00 0 ❑ 0 O 0
❑ d as owner of the property,he exclusively contracting with
licensed contractors to construct the project La 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:Thr Conbuilds o 1-teens,Law duos not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contraclod s)licensed pursuant to
SEWER-SAN V-STORM EA.200(1/10.00 TRACT NO. PARCEL NO.
tie Contractor's License Law.
❑ I am exempt under Sec. .B.&P.C.till this WATER HEATER W/VENT 6.00
Peas n
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'CONPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hemby affirm that I have a certificate oI consent to wil-innure. ZONING ENG.S17E NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof '.3800,LaIE CA
Policy No. Company -
O ❑ Celli t' ropy is her f fc FIRE SPRINK ENERGY T-24
Z 2 Ce tt" d cop is with,,V city inspection division. MISC.- REFER TO ORD.
IYpplica Y ❑ N❑ Y ❑ N❑
2rn ,IiRTIF'IC'A'I'E OF EXEMPTION PROM WORK ERS'
PERMIT ISSUANCE 10.00 ZV••jj�� FLOOD ZONE A.L.U.C.
W ? COMPENSAI10N INSURANCE PLG.CONTE. LIC.NO. TpTAL -OI/ Y� IN E] Y � N�
1 0 CI In, section need not be completed if the permit is for one
Z hundred dollars($100)ar Ics1J
U O 1 certify that in the performance of the work for which lhls per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
1t, H mit is issued,I slmll not employ any person in any Runner so as In
OU beconmsuhjcct to the Worker Compensation Laws of California. BUILDING Oed
Daly Applicant ALTER OR ADD TO MECH. 5.00
} Ge NOTICE;10 APPLICANT: If,after making this Certificate of Ex..
I. ? caption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must torthwilh conpsly will,, FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 4.00 r
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=CF.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance al'the work lir which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,CiP.C.1. /
Lenders Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC S'6E3�
Lender's Address
I Certify that I have read this application and Slate that thf above VENTILATION FAN (SINGLE) 4.00 Q
information is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 g.UD PLUMBING
ordinances and .alate laws relating to building construction, and
hereby authorize representatives of this city to enter upon tha gQILER-COMP IOver 100,000 BTU)SEE FEE SCH. C NI 3 -
above-mentioned property for inspection purposes.
(We) agree to save, rudenmify and keep harmless the City of MISC.- REFER TO ORD. r1�
u9',o against liabilities,judgments. toss and expenses which PERMIT ISSUANCE 10.00 p4 CONST.TAX
saany way accrue a l sat City in consequence of filo
Of this pen [. 1 ? ECH.CONT. LIC.NO. MECH.
�Z �+ TOTIfL -`� AL p
igufure of Applicant/ onlractir
OFFICE COPY