10042APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BkH LDI NG PROJECT IDENTIFICATION
APPLICATION &PERMIT
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL/
PERMIT NUMBER
1OO TZ
neo rjU
�VGT�
OWNER'S
NAM
e,q
V. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
(%Ll/lF- PHONE
NAMECONT
Q OUTLETS- SWITCHES -RECEP 10.00/1.00
OUTLETS
UC. No.
P LIGHTING FIXTURES 10.00/1.00 111e
ADDRESS
APPLIANCESTORS PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
PHONE
DATE OF APPLICATION
OARCHITECTPANELS
ENGINEER
LIC. NO.
(OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
ISIGNS TRANS. 3.00
ENG.
ADDRESS
5.00
SPECIALCIRCUIT 6,00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
ZIP
/I
APPLICANT
E
RAMOTORS FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
TEMP. POLENMI 30.00
City
I hereby affirm that I an licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and any license is in full force and effect.
License Class Lic. Number
I33 /ANCE OATE
BLDG. ELECT. PLG. I MECH.
E) El
Date Contract Or
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Businessand Professions
Code: Any city or county which requires a permit to construct, alter,
BUILDING PERMIT
INFORMATION
MISC.- REFER TO ORD
PERMIT ISSUANCE 1000
. Q
VALUATION
$/FT.
ELEC. CONTR. LIC. NO. ELEC. ? ,(6 Oj(i
TOTAL
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
PERMIT TO
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
T . PLUMBING PERMIT FEE
�G�l' "
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of am more than five hundred della" (5500).):
STORIES
TYPE CONSTR.
ALTER -DRAIN -WATER (EA.) 5.00
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND.' 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
F IXTUR ES - PER TRAP 5.00
GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
30. FT. FLOOR AREA
TOTAL ACREAGE
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
mentsarenot intended or offered for sale. If, however, the building
Or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or im-
prove for purpose of sale.).
❑ I, its owner of the property, am exclusively contracting with
BUILDING USE
RES IND CON PB Other
E] El C1 E] C1licensed
INDUSTRIAL WASTE INTER. 30.00
contractors to construct the project (Sec. 7044, Business
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 - 1 INC 5 V.B. 600
.
LAWN SPRINKLERS - OVER 5'(EA.) 1.00
ASSESSORS PARCEL NO.
ed pursuan to
the ('ontrat LiC nse Law
❑ a xemp-t J S.&i'. . f finWATER
commcis (o h projects wi"CLARA
SEWER -SANITARY -STORM EA. 200f1/10.00
TRACT NO.
PARCEL NO.
HEATER W/VENT - 6.00
Ownate
WATER SYSTEM 5.00
ACC.DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WORKERS-COMPITI
1hereby affirmhat I havto self ..sure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE N0.
Copy thereof (Sec. 3600, Lub.0.).
-
Policy No. Cmnpany
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division.
Applicant
MISC. - REFER TO ORD.
FIRE $PRINK
Y ❑ N❑
ENERGY T -Z4
Y ❑ N❑
CERTIFICATE OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOODZONE
A.L.U.C.
COMPENSATION INSURANCE
(This section need not be completed if -the permit is for one
Y ❑ N ❑
Y ❑ N ❑
PLG. CONTR. LIC. NO.
PLG,
TOTAL
hundred dollars ($100) or It..)
,
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so as to
Y MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
'
become subject to the Workers' Compensation Laws ofCalifornia.
Date Applicant
ALTER OR ADD TO MECH. 5.00 S�
NOTICE '1'O APPLICANT: If, after making this Certil'icum of Iix-
APPLIANCE 5.00
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
PLAN CHECK
FEE
emotion, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith Comply with
such provisions or this permit shall be deemed revoked.
AIRHANDLING UNIT(OVER 10= 0
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm (hut 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.
3097, Civ.C.).
-
HEATING UNIT (TO 100,00
MICROFILM
Lender's Name
Lenders Address
Lender's
H EATI NG U N IT 100,000B.T. -18.50
ELECTRIC
3pov
-v
1 certify that 1 have read this application and state that the above
VENTILATION FAN (SINGE
information is correct. I agree to comply with all city and county
ordinances and slate laws relating to building [onstruclion, and
PLUMBING
BOILER .MW(3H.P.or100,00 .T..1 6.00
BOILER -COMP (Over 100,000 BTU) SEE PEE SCH.
MECHANICAL
S-f/le
hereby authorize representatives for ins ec this city es cote( upon the
habove ereby mentioned property for inspection purposes.
(Wa) agree to save, indemnify and keep harmless the City of
o against liabilities, judgments, costs and expenses which
u y way accrue against said City in co equen of the
/(
451
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 10.00 /O -
MECH. CONT. LIC. NO.
MECH.S.P7,
TOTAL
e of Applicc nt/Conlm D, e
III, OFFICE COPY