5068 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT 5068
/ AOOREss n �'1
J` S o(_FE IZ;V BUILDING
-ELECTRICAL-PLUMBING-MECHANICAL
0.1.S PLAN CHECK VALIDATION
NAI tE^� /TSA'/ CITY. ELECTRIC PERMIT FEE
' (loff I
NE
-
CONTRACTORS
NA OUTLETS-SWITCHES-RECEP 5.00/1.00Ae4FfC �-'19J /^w',LIC NO3030( LIGHTING FIXTURES 5.00/1.00
coNTRACTObx HO
Es PPLIANCES-RESIDENTIAL 4.00
/Q]RE$f$Lr q
'htSIaO PNE q1 ,7PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00
APPLI MOTORS SEE FEE SCH.
ss
ADDRDDH ESS
SERVICE CHANGE 10.00
o O LICENSED CONTRACTORS DECLARATION
<u U I hereby affirm that I am licensed under provisions of Chapter) ISSUANCE DATE
m <w Icnmm�cing with Section 70001 0l Division 3 of the Business and BLDG. ELECT. PLG. MECH.
m
F Professions Cotijhiry license is in I ell t' d I s ❑
z o u'"i License lass __!!TNmnl 9 - ❑
Q N E w ate -yL�Contrazm
m ¢ sr "` ��-0 -.IIiR BUI ., DI LA ATION BUILDING PERMIT
Ir w D REFER TO ORD INF TION
LL . I hereby affirm that I am exempt front Ile Contractor',,Limine ISC.-
w o 4 Law for the following reason.(Scu.7031.5.[justness and Professions ISSUANCE V wATI SIFT.
r - Code:Anycityorcounly which re4uiresa permittoconstruct,alter.ur 6.00 q 7O
lie a 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O u requires the applicant for such permit to file a signed statement that TOTAL -PERM[ TO
a wire
is licensed pursuant to the provisions of the Contractor's License n�.i• _ /
rzi
Law(Chap ter 9(commencing wi t IT Sect ion 7000)o If Div inion 3 of t he U tr'V
a Business and Professions Code)or tint he is exempt lhcrefronh and CITY. PLUMBING PERMIT FEE
¢ I tie basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ; $ by any applicant for a permit subjects lire applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
Of not more than five hundred dollars(S500).):
❑ I,as owner of the property,or my employeeswith wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:'file Contractor's License Law docs not apply to an owner of
mnperty who builds or improves thereon,and who dues such work F IXTUR ES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
40 himself or ttrough his own employees,Provided that such improve-
ments are not intended or offered for sale If,however the building GAS-EA.SYSTEM-1 INC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
proveforpurposeofSale,). INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB ower
❑ I,as owner of the property,3m exclusively conlracling with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044.Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 A55ESSOHS PARCEL NO.
and Professions Code:'Ilie Contractor's License Law docs not apply
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractoDs)licensed pursuanl to
lire Contractors License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ 1 urn exempt under Sec._.B&P.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSAT ION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate ofconsent to elf-in,ure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy there (Sec.3800,Lub.Ca.
Polic Company_-
Q C 'fie copy is largily Ili n.eihed. FIRE SPRINK ENERGY T 24
Z Z ❑ C rt i copy i In a'th lire city ins eclim ivision. MISC- REFER TO ORD.
O Aiplican - _ Y NEI Y ❑ N[]cr In CEIR FICS'l'SOF EXehf P11ON FROM W'OI CI?RS' PERMIT ISSUANCE 6.00 1 FLOOD ZONE A.L.u.C.
Lu >_ CO MPF,NSATION INSURANCE PLG.CONTE. LIC,NO. PLG.
EL o 11 An need not be completed if the pen T Fs for m, TOTAL Y❑ N❑ I Y ❑ N❑
Z) 2 hundred i llars(5100)or less.)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL P mit is issued,1 shall not employ any person in any manner so as to p
OL) become subject to the Worken'Compensation Laws of California. BUILDING �O 's0
Date Applicant ALTER OR ADD TO MECH. 4.00
>- tan NO'f1CI. '10 APPLICANT: If,after making this Certificate of Ex-
F.. ? emptier,,you should become subject to the Workers Compensation APPLIANCE 4.00 PLAN CHECK
provisions of tin Labor Code; you must forthwith cempl, with FEE
U such previsions or[his permit shall be deemed revoked . AIR HANDLING UNIT(TO 10,13MCF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(See. MICROFILM
3097,CiN.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county BOILER-COMP13 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and stale laws relating to building construction, and
hereby andiron, representatives of this city to enter upon the BOILER-COMP [Over 100,000BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save indemnify and keep harmless the City of MISC.- REFER TO ORD.
C crone against liabilities,judgments, costs and expenses which CONST.TAX
m uny wayacgenst said City in consequence of the PERMIT ISSUANCE 3.00
gr nhis permi. MECH.CONT. LIC.NO. MECH.
TOTAL TOTALSignI ArplIMAICTMtractor Dale
OFFICE COPY