4085 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
ADDRESS 4085_
Q C TBUILDING-ELECTRICAL-PLUMBING-MECHANICAL
O N R'S T - PLAN CHECK VALIDATION
-mac NAME 25'77000 QTY. ELECTRIC PERMIT FEE
��✓ PHONE
NAMERAcroRs UTLETS-SWITCHES-RECEP 5.00/1.00
LIC.NO, LIGHTING FIXTURES 5.00/1.00 '
CONTRACTORS
R's
ADPPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER
` - uc.No. SIGNS TRANS. 3.00
ARCH.OR ENG. - PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
w
zlv TEMP. METER OR POLE INS. 15.00
APPLICANTS
MOTORS SEE FEE SCH.
ADDDRESSDRESSC )
SERVICE CHANGE 10.00 ?9/157
/O J
w O o LICENSED CONTRACTORS DECLARATION
.Q
to I hereby ul'Ofm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
y Q c SLOG. ELECT. PLG. MECH.
F 7 i Professions Code,and my license is in full force and effect. ❑ ❑ ❑
O i W License Class LiC.Number
m r Dale Contractor �I�qIp�
a w ¢ - OWNER-BUILDER DECLARATION I VUBATION PERMIT
oa " MISC.- REFER TO ORD
E
3 I- I hereby affirm thm I am exempt from the Contractor's License
r _ o j Law far the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00 VALUATION $/FT.
w� Code:Any city or county which requires a permit to construct,alter, 9 8 1JO
rt Q 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. '�Jh v JO
d it DLL requires the applicant for such permit to file a signed Statement that TOTAL PERMIT TO
wm he is licensed pursuant to the provisions of the Contractor's License sp�sr�p�
rzi Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe 7 yuWfI�/T�"Rf
Q Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
.IS the basis for the alleged exemption.Any violation of Section 7031.$ STORIES ')TYPE CONSTR.
La
dam _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4,00
of not more than five hundred dollars(S500).)r
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 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, Busmess and Ptofesslom DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner Df -
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or improvement is sold within one year of completion; the owner- GAS EASYSTEM OVER 4 (EA) 100 BUILDING USE
builder will have the burden of proving that hu did not build or in - . - , .
t- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER
❑ 1,as owner of the property,am exclusively contracting with . 20.00 ❑ _❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contrmlar's License Law docs 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 cuntraetor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ tum exempt unite &f'1:.for it,I, WATER HEATER W/VENT 4.00
reason 11
DaH,_ ` - - WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'CONII'ENSA'I'ION DECI.ARAI'I N TER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent h self-insure, ZONING
ora certificate of Workers'Compensation Insurance,or a certified ZONING SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
0 ❑ Certified copy is hereby fuuukhed RE SPRINK ENERGY T-Z4
2z Z ❑ Certified ropy is filed with the city inspection division, f MISC.- REFER TO ORD. '
O Applicant Y ❑ N❑ Y ❑ N❑
~ in PERMIT ISSUANCE 6.00
� 'CERTIFICATE 017 SAEIOTINS FROM WORKERS' FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLc.coNTR. LIC.ND. PLG.
0. 0 ffhis sectiim need not be completed it the Permit is Iol one TOTAL Y❑ N❑ Y ❑ N❑
7) Z hundred dollars($100)or less.)
U O 1 certify tile(in the performance of the work for which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
Uy 1- mit is issued, I shall not employ any person in any manner so as to
0 W become subject to the Workers'Compensutian Laws GO Culilimlia.
Date 'Applicant BUILDING -0
• 0. ALTER OR ADD TO MECH. 4.00 �p
>_ W NOTICE 'f0 APPLICANT: If,after making this Certificate of Ex- `��
F. emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK _
provisions of the Labor Code, you must forthwith comply with •y Z
U such provisions or tmFEE
CONSTRUCTION
permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 3.00 oC s
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,0000F.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(Sec. MICROFILM
3097,CicC.) H EATING UN IT(TO 100,000 B.T.U.) 4.00
Lender's Nwne HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
1 certify that I have read this application and state that he above VENTILATION FAN (SINGLE) 3.00
information n correct I agree ti comply b with nil city ucti county PLUMBING
ordinances unit state laws reeling m building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the
above-mentioned properly for inspection purposes. BOILER-COMP (Over 100,000 RTU(SEE.FEE SCH. MECHANICAL
live) agree to save, soil Ify unit keep harmless the City of MISC.- REFER TO ORD.
%lCul tino ugai Ilahiliti dgmm�ts, costx mid exponxcs which PERMIT ISSUANCE 3.00 CONST.TAX
in ay cent a nut aid City in consequence of the p lit MECH.CONT. LIC.NO. - MECH.Iq TOTAL TOTALppllc nt/Contractor Data - -
OFFICE COPY