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APPLICAN O FILL IN INFOR ION WITHIN REO LINES - USE BALL POINT PEN ONLY
PERMIT NumBEH
BU LDING PROJECT I DENTI FICATI ON
aDILDINc APPLICATION & PERMIT 112 21
AooR Ess
1 p Tpel1 ^ _ BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
I or
OWNER'S PLAN CHECK VALIDATION
r "AME QTY. ELECTRIC PERMIT FEE
(i RUNE
CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
p uc.No. LIGHTING FIXTURES 10.00/1.00
ADDDDRESSRESS ow's APPLIANCES-RESIDENTIAL 4.00
ADDRESS
II 6f PHONEZ 2 (f- PANELS 10.00 7 DATE OF APPLICATION
ARCHITECT
PANELS (OVER 200 AMP) 20.00 PLAN CNECK FEE P.C.NO.
op
ENGINEER SIGNS TRANS. 3.00
0.NO.
AR. ENG, CIRCUIT 5.00 PERMIT VALIDATION l
ADDDDRESSSS
zlv EMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH. n
ADDRESSU1L`_
SERVICE CH GE 20.00 Grp
woo LICENSED CONTRACTORS DECLARATION 17
a I hereby affirm that 1 am licensed under provisions of Chapter 9 •� ISSUANCE DATE
H G w (commencing with Section 7000)of Division 3 of 1he Business and BLDG. ELECT. PLG. MECH.
H N z .Professions Cude,and m license is in full fojjec�und effect r ❑
License Cl CC=l tic Nunber�'1_�7�� ``� 1
O u F o- Date_y.. f�$�Contnctor.jlLM SSB-P'--
fJ BUILDING PERMIT
a a w u OWNER-BUILDER DECLARATION INFORMATION
w0
LL w I hereby alfinn that I am exempt Gam the Contractor's License M C.- REFER TO ORD
Huo < Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 U VALUATION $/FT.
W
Code:Any city or county which requires a permit to construct,alter,
s a Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.GONTH. LIQ NO.
ELEG. D`r.
o ¢ requires the applicant for such permit to file a signed statement that S TOTAL PERMIT TO
a w m u he is licensed pursuant ,,0n provisions of the Contractor's License
F z r Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
< Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
r the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
To ; by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollar.,($500)J'.
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC,GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Pluellions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
himsellor through his own employees,provided that such improve-
merits are not intended or offered for sale.If,however,the building GAS-EA.SVSTEM-11NC.40UTLET$ 6.00
or improvement is old 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 in* RES IND CON PS Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ 1:1 ❑ ❑
❑ I,as owner ol'tire property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSOHS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such projects with a contortions)licensed pumarint to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ I am exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 6.00
rea9011
owner Dan WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK E RS'COMPI?NSAT'ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to self-insure. ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(See.3800,Lab,C.))
Policy No.-
Q ❑ Ccnilied is he Cby furnis'hcd. FIRE SPRINK ENERGVT2<
z _ ❑ Certi(' opy_ ded ,pCCUoR division. MISC.- REFER TO ORD. y IN y N�
F vpj/.J. Applican
=y CT.RT'IFICATEOF EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD zoNE A.L.u.c.
L 0
>_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
TOTAL V N V N
(This section need not be completed if the permit is for one
Z hundred dollars(8100)orlessJ FEE SUMMARY
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE
LL F mit is issued,I shall not employ any person in any manner so as to
O w become subject to the Workers''Compensation Laws of California. BUILDING
Date Applicant ALTER OR ADD TO MECH. 5.00 777
} N NOTICE TO APPLICANT: If,after making this Certificate of nix- 5.00 PLAN CHECK
r Z emption,you should become subject to the Workers'Compensation APPLIANCE
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked, AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 MICROFILM
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 9.00
3097,Civ.0 J.
Lender's Name HEATING UNIT 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 PLUMBING
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
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to corer upon the BOILER-COMP (Ova,100,000 BTU)SEE FEE SCH. MECHANICAL
I✓ abuvomentioned property for inspection purposes.
(We) to save, indenmify and keep harmless the City of MISC.- REFER TO ORD.
Cup• mo ainst liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may n y use re against said City in consequence of the
g g oft]is h MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
6 ����
'gnaNre of pplicant/Contractor lute
OFFICE COPY