9495 APPLICANT TO FILL.IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY .
BU I LDING PROJECT I DENTIFICATION PERMITNUMBER
BUILDING APPLICATION & PERMIT 9495 n C
aooRE s • `J' a7 t�
C/ � z WE00.b�Q D� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
\ wNER'B PLAN CHECK VALIDATION
NAM ELECTRIC TV. ELECTRIC PERMIT FEE
R.p�J PNONE -�
CONTRACTORS //� � 'O UTLETS-SWITCHES-RECEP 10.00/1.00
N&O,D S g/LC/q.�C..,,C.NoG O 3T4 LIGHTING FIXTURES 10,00/1.00
C NTRACTORs a APPLIANCES-RESIDENTIAL 4.00
OORE;s /�/
�)V;_ MelovNONE ZC-7I1710�PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.RENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESSZIP rrEMP.METER OR POLE INS. 20.00
ADDRESSTs MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 /p
0 '
woo LICENSED CONTRAC'T'ORS DECLARATION TEMP.POLE 30.00
a i w I hBfR
erehy rm ut
Thal 1 am licensed mer provisions of Chapter 9 'D d ISSUANCE DATE
a n (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H N i Professions Code,and my license is in full force and effect. �1 /+
Q i m W License Class hie.Number AUG '� F ' ❑ ❑ ❑ ❑
F m H J Dme Contractor IN
a x s -. BUILDING PERMIT
I. 0 6 U OWNER-BUILDER DECLARATION MISC.- R no INFORMATION
a'xl ; y I hereby affirm that 1 am exempt from the Contractor's License VALUATION S/FT.
.,
o as Professions PERMIT ISSUANCE 10.00
Law for the following reason.(Sec.7031.5,BuslneSSaBd Pfessi4L
- Id
Cope:Any city or county which requirese permit meonsua construct,,also
IS ¢ ¢ FO improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. �yYJL
wD IS requires the applicant for such permit to file a signed statement that TOTAL t7 s.J PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
rZi
Law(Chapter 9(commercing with Section 7000)of Division 3 oflhe
4 c Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
a r$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i; � by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,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 Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractors 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 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
•- mems are not intended or offered for sales ll',however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner
builder will have the burden of proving that Ile did not build or im. GAS-EA.SYSTEM-OVER 4 (EAJ 2.00 BUILDING USE
prove for purpose ofsale.). RES IND CON PB Onto,
Cl I,;is owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30,00 ❑ ❑ ❑ ❑ ❑
licensed contract.. to construct the project (Sea 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESS RSPARCEL NO.
and Professions Code:The Contractor's License Luw 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 conlmetor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO, PARCEL NO.
❑ I:un exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a eerlifieme ofcI nScnt to eeiBin sure,
or a certificate of Workers'Compensation Insurance,or a certified
ZONING ENG.SITE NO.
copy(hereof(Sec.3800,Lab.C.).
Policy No. Company
Cl Certified copy is hereby furnished. FIRESPRINK ENERGY T-24
❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
Applicant Y ❑ N❑ Y ❑ N❑
CERTIFICATE OF EXEMPTION I7ROM WORKERS' PERMIT ISSUANCE 1000 FLOODZONE A.L.U.C.
a COMPENSATION INSURANCE PLG.CONTR. Lae.NO. PLG.
0 ('Phis section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
hundred dollars(S 100)or Ics,)
L) O I certify that in the performance of The work for which this per. CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not empl&any person in any manner so as to
O w barn sayyl�i tipp�fWO'lo s ensyy' LawsofdCalb orni
a Date/.,]1YApplicanl n-f��"^'�� ALTER OR ADD TO MECH. 5.00 BUILDING
} Tn NOTI Tb APPLICANT: If,after making This Certificatit of E.
F 2 amPlion,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 Acemed revoked. AIR HANDLING UNIT(TO 10MC.F.NL) 4.00
CONSTRUCTION LENDING AG17NCY AIRHANDLING UNITIOVER 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
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is with correct. I agree to complywall city and county PLUMBING
ordinances and stale laws relating to with
construction, and BOILER•COMP(3H.P.or100,0008.T.U.1 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes BOILER-COMP(Over 100,000 BTU(BEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
ertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
nes 'n any way accrue against and City in consequence of the
g alit ofthisper MECH.CONT. LIC.NO. MECH.
11� 4-/s•' TOTAL TOTAL
/1 Si a¢ve of Applica rt/C ntraclor Dale
1 I OFFICE COPY