12188 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
.UH-DING APPLICATION & PERMIT 12188
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O _ G BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
OWNERS PLAN CHECK VALIDATION
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,J/„ OTV. ELECTRIC PERMIT FEE
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CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
�• LIC.No. LIGHTING FIXTURES 10.00/1.00
.ONTRACTOR'S ��� PPLIANCES-RESIDENTIAL 4.00
ADDRESS /J 17Ww,` O//�
/ ��^6 PHONE4/,j2'pr "7�� PANELS IO.00 DATE OF APPLICATION
IARCRITECT PAN ELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.rvo. SIGNS TRANS. 3.00
AR. ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDDDRESSSS 8'1/
_ zip A l
EMP.METER OR POLE INS. 20.00 e ,
APPLICANT'$ x /,r
ADDRESS MOTORS SEE FEE SCH. r/I1 Uf IfIO'
ISERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION l
< v u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
N rt m mm
(coencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
w-m Z: Professions Code,and my Dcense is in full force'ad effect. ❑
Z o w - License Class_(,'=t1.,�j_Lic.1, nibed,44 ❑ ❑ ❑
9 r w Date U/ q�../U.�Con trad „e.,�,,_.� )
0 x �"C�/"C( BUILDING PERMIT
E a w OWNER-BUILDER DECLARATION INFORMATION
E:
LL y I hereby alfrm [hat I am exempt from the Contractor's License MISC.- REFER TO ORD
LL O a Law for the following reason.(Sec.7031.5,Business and Professions VALUATION $/FT.
F _ PERMIT ISSUANCE 10.00 O /�
or I Code:Any my or county which requires a permit to construct.alter,
ic Q Q p ImprOVQ,demolish,or repair any structure,prior to Its Issuance,also ELEC.CONTR. LIC.NO. ELEC.
D IS requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
d w m he is licensed pursuant 10 the provisions of the Contractor's License
F z i
Law(Chapter 9(commencingwith Section 7000)of Division 3 of the Er'\/S
sr Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
r $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
w. by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500l)
C 1,as owner of the property,or my 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 sal.(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law docs not apply to an owner of
• property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve GAS-EA.SVSTEM-1 INC.40UTLET$ 6.00
Dents arc not intended or offered for sale.If,however,file building
or improvement is Sold within one year of completion,the owner GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or int- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors m construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The ConLacmr's License Law does 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 contractor(s)licensed pursuant to SEWER-SAN ITAR V-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
re❑n I am exempt under Scc,-.B.&P.C.for this WATER HEATER W/VENT 6.00
Ow o
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a Certificate ofconsent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ CcRified Copy is hereby famished FIRE SPRINK ENERGY T-24
Z Z Certified co Gley/��w)�h the city inspection division. MISC.- REFER TO ORD.
Ap IiCantit`^- a Y❑ N❑ Y ❑ N❑
CC O CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.O.C.
LU > COMPENSATION INSURANCE PLG.CONTR, LIC.NO. PLG.
CL O (This section need not be completed if file permit is for one TOTAL v E) N❑ v[:] N[]
D Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which Ibis per JEXHAUST
MECHANICAL PERMIT FEE FEE SUMMARY
Ly H mit is issued,I shall not employ any person in any manner so as to
Q L) become subject to the Workers'Compensation Laws of California. BUILDING 620
Date Applicant OR ADD TO MECH. 5.00
} tail NOTICE TO APPLICANT: If,after making this Certificate of E.-
♦- Z cmption,you should become subject m the Workers'CompensationANCE 5.00 PLAN CHECK Zt% ,�Z
Provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. NDLING UNIT(TO 10,000GF.M.1 4.00
CONSTRUCTION LENDING AGENCY NDLING UNIT(OVER 10SMC.F.M.) 6.00 SEISMIC FEE I 7
1 hereby affirm that there is a construction lending agency forUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued ISec. ING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.C.l.
Lenders Addi `� I NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC /�,Lender's Address `ertfy that I have read this application and statethattheaboveILATION FAN (SINGLE) 4.00information is correct. 1 agree to comply with all city and countyR-COMP(3H.P.or 100,000B.T.U.) 6.00PLUMBING
ordinances and state laws relating to building construction, ironhereby authorize representatives of this city to enter uponlhuR-COMP (Over 100,000 BTU)SEE FEE SCH.above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harless the City of - REFER TO ORD.
Cuperb inn against liabilities,judgments, costs and expenses which CONST.TAX
may in an ay accrue against said City in consequence of the PERMIT ISSUANCE 10.00
J����granting t Pennil. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL �05�
�ir ure of p loam/Con raL�Dateure of p Imam/Con ruL�Uate
OFFICE COPY