12797 c3
NT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
I NG.PROJECT I DENTI FICATION PERMIT NUMBER
- APPLICATION & PERMIT
010 !'1� Q BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 12797
OWNERS-- .V PLAN CHECK VALIDATION
NAME CITY, ELECTRIC PERMIT FEE
HONE `\
TRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
NAME v.„ �Q /W
L,D.NO. LIGHTING FIXTURES 10.00/1.00 T 6 15_
CONTRACTOR • 1 PPLIANCES-RESIDENTIAL 4.00
PHONE e0_1 4OZ PANELS 10.0D DATE OF APPLICATION
ARCHIT - PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR ` �
ARCH.EER NC �' VA
LIC,NO. SIGNS TRANS. 3.00
ADDRESS ErvG. 1 � �C �[\ SPECIAL CIRCUIT 5,60
PERMIT VALIDATION
ADDRESS WJ O �'ir
ZIP EMP.METER OR`POLE INS. 20.00 l\
APPLICANT x a MOTORS �M SEE FEE SCH. ^
ADDRESS ``�I�,IIV//"' 'I
SERVICE CHANGE 20.00 I
w o o LICENSED CONTRACTORS ECLA RATION �l
< U U I hereby affirm out 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
y a w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT, PLG. MECH.
F N z Professions Code and my license is in full force n�tif� ❑ ❑ ❑ ❑
Z o o - License ss Lic.Number
Q v, r w Data Caoractor xSGL•_IA.Pm
a r F st p���.n BUILDING PERMIT
E tr: w OWNER-BUILDER DECLARATION V..YNS'Qu- INFORMATION
w3 w n I hereby afOnn Ihm I am exempt from the Corrector's License MISC.- REFER TO ORD
F-
I. oJ Lawforthefollowingrcason.(Sec.703L5,Buslnessand Professions PERMIT ISSUANCE 10.00 � - vnLunnON $/FT.
Code:Any city or county which requires a permit to construct ager, is
2 Q improve,demolish,or repair any structure,prior to its issuance,also E CONT I�C._NO. ELEC.
- DLL requires the applicant for such permit to file a signed statement that
' 1.J TOTAIL PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's License / �> �-
w z i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe �C-A"' /V/L &Z&V¢7u
a Business and Professions Code)or that he isesempt therefrom and DTV. PLUMBING PERMIT FEE
arc the basis for the alleged exemption.Any violation of5ectlon 7031.5 STORIES TYPE CONSTR.
a ;m by any applicant for a permit subjects the applicant toacivil penalty ALTER-DRAIN&VENT-WATER IEA,) 5.00
of not more than five hundred dollars(8500).1'.
❑ 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCD.GROUP RES.UNITS
their Sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7144, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
a himself or through his own employees,provided that such improve-
mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
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 the did not build or im- RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner.1 tire property,am exclusively contracting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 MA.) 1.00
contracts for such projects with a contraclons)licensed pursuant 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
reason
owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a Certificate ofconsent to self-insure, ZONING ENG.SITE NO.
a certificate of Workers'Compensation Insurance,or a certified
c
n py thereof Bee 3800,Lab.C.lt.)�C�-(�+
Policy No. Company SA - -3F1LJ,l'w
Q ❑ Certlfle 'OpyiSherebyfurnl5hed. FIRESPRINK ENERGY T24
Z2 � Certi 'e coy is filed with the city inspection division. MISC.- REFER TO ORD. y0 N� y NEIicant
F rrr° A?pl11 PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
Cr - CERTIFICATE :h I 'hI`VORKERS'
Lll >_ COMPENSA'I'IONINSURANCE PLG.CONTR. LIC.NO. PLG. y� N� Y � N�
d 0 1'I'his section need not be completed if the permit is for one TOTAL
Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- OTV MECHANICAL PERMIT FEE FEE SUMMARY
LL P mit is issued,1 shall not employ any person in any manner sn as to
O0 beconw subject to the Workers'Compensation Laws of Calitormo BUILDING
Dale Applicant ALTER OR ADD TO MECH. 5.00
} y NOTICE 10 APPLICANT: U.after making this Certificate of Cx-
? 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 1OXMC.F.M.) 4.00
CONSTRUCTION L17NDING AGENCY AIR HANDLING UNIT(OVER 10MC.F,M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5,00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT IT
100,000 B.T.U.) 8.00
/aU•\ Lender's Name HEATING NIT(OVER 100,000B.T.U,)9.50 ELECTRIC 3�
i 1 Lender's Address
1
I certify that I have read this application and stale that lire above VENTILATION FAN (SINGLE) 4.00
information n correct I agree to comely with all nlY and county
BOILER-COMP(3 H.P.or 100.000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construmion, and
hereby authorim representativf:s of this city to enter upon the BOILER-COMP(Over 100,000 BTUI SEE FEE SCH. MECHANICAL
abovomentioned property r' spection purpous.
agree ,o save, in emnl' and keep harmless the City of MISC.- REFER TO ORD.
C pert ins, liubil,,,e ,judg cots costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
n y u ,true a ainst . id in conseq cote of the
g nt Ih •rt �� MECH.CONT. LIC.NO. MECH,
TOTAL TOTAL
Sign 1'Applicant(Conlruu. Uato
OFFICE COPY