15675 (2) APPLICANT TO.FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION ^" -' - PERMIT NUMBER
BwLWNG APPLICATION & PERMIT, M1 ` [ f]
AD {ys L' f. J
Vj BUILDING -ELECTRICAL-PLUMBING--MECHANICAL . J
OWNER'S
NAM , PLAN CHECK VALIDATION
,r' 1 DTV. " ELECTRIC PERMIT FEE , -
TRl I PHONE
CONTRACTOR'S
"A G'/U qq���`��� OUTLETS-SWITCHES-RECEP 10.00/1.00
lv 4 C.Na. 7yt.CJ LIGHTING FIXTURES 10,00/1.00
CONTRACTOR'S -
ADDRESS 2..1r// ,�7 PPLIANCES-RESIDENTIAL 4.00
"jPI NNEZ�3 4�� PANELS 3&g0
ARCHITECT .�/ DATE OF APPLICATION
OR PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P,c.No,
ENGINEER'
UC.NO, - Ella.NSTRANS.' 3.00
ADDR.SS ENa CIAL CIRCUIT 5.00 PERMIT VALIDATION '-
ARCHE08
ZIP - METER OR POLE INS. 20.00 -
APPLICANT'S' I
ADDRESS MOTORS _ SEE FEE SCH.
SERVICE CHANGE
wo o LICENSED CONTRACTORS DECLARATION
a v 1 hereby affirm that I am licensed under provisions of Chapter 9gSSUANCE GATE
a y (commencing withp Section 7000)of Division 3 of the Business and -
r zi z- Professions Cooyy I my license is in full fore f��pat ELECT: 1 PLG. MECH.
Z o w - License Cl s`` Lic.Numb W ❑ '.i'❑
4 w t O Dole (�'�4�'•' V Contractor ),
My E J ^ I p
o i <. OWNER-BUILDER DECLARATION V BUILDING PERMIT -
MISC.= REFER TO OR INFORMATION
K
g LL v, 'I hereby affirm that I am exempt from the Contractor's Pr License VALUATION
H ._ o j Law for the following reason.(Sec.7031.5,Business and Professions PERMIT'ISSUANCE - - $/ T.
Code:Any city or county which requiresa permit to construct,alter,
0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. - ELEG.' q
i
e u requires the applicant for such permit to file a signed statement that _ TOTAL OC c
X m he Is licensed pursuant to the provisions of the Contractor's License PERMIT TO
,H Z a Law(Chapter 9.(Commencing with Section 7000)of Division 3 oftbe T -
z.o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE � - r
1- the basis for the alleged exemption.Any violation of$ection 7031.5 STORIES TYPE CONSTR.
n3L' by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN 5.00
of not more than five hundred dollars($500).): -
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP' RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply W an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP .,r 5.00 S0.FT,FL00R AREA • TOTAL ACREAGE
himself or through his own employees,provided that such such
improve-
mentsam lot intended or offered for sale.If,however,the building GAS-EA.SVSTEM-11NC.4OUTLETS 6,00
or improvement is sold within one year of completion,tiro owner- GAS-EA.SYSTEM-OVER 4(EA.)' 2.00
builder will have the burden of proving that he did not build or int- - BUILDING USE
prove for purpose of sale.). RES ,IND � CON PB Other
❑ 1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. - 30.00 ❑ ❑ ❑ ❑ ❑
licensed Contractors to construct the project(Sec. 7044,BusinessM
SPRINKLERS 1 INC 5 V.B. 6.00 ASSESSORS PARCEL No.
and Professions Codes The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and whoKLERS-OVER 5(EA:) 1.00
contracts for such projects with a contractors)licensed pursuant to -the Contractor's License Law, ITAR V-STORM EA.200ft/10.00TRACT No. PARCEL No.
U I am exempt under Sec. B.&P.C.f ii flitsreason TER W/VENT 6.00Owner DateL +TEM S.00 ACC.DATE - ACC.FILE NO.
WORKF.RS'COMPENSATION DECLARATION ATING EQUIP. 5.001 hereby affirm that 1 have a certificate ofConsent to self-insure,
or a certificate of Workers'Compensation Insumnce,or a certifiedZONING; ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).Policy No. Companyt❑ Cer tied copy is hereby furnished. FIRE$PgINK t._ ENERGY TR4
Z Z � Cert it copy 0 d with the crt� ns a bn division.
FO PIA cant '� t i -- MISC.- t - REFER TO ORD: - 11 N❑ y ❑ N❑
it CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 ,FLOOD ZONE A.LU.C.`
W COMPENSATION INSURANCE PLG.CONTR. .LIC.NO. PLG, - 1'
O_ ('This section need not be completed if the permit is for one TOTAL - Y N� y N�
Zhundred dollars($100)or less.) r -
I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL'F- mil is issued,I site]]not employ any person in any manner so as to
Q W become subject to the Workers'Compensation Laws of California. -
y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} Uf NOTICE TO APPLICANT: IL after making this Certificute of Ex-
Z 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
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10AMC,F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(EVER 10,000 C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITHthe performance of the work for which this permit is issued(Sec: - MICROFILM '
3097,Civ.CJ. HEATING UNIT(TO.100,000 B.T.U.) -8.00
Lender's Name HEATING UN IT 100,000 B.T.U,)9.50
'- Lender's Address ELECTRIC.
i I certify That I have read this application and state Thai the above VENTILATION FAN (SINGLE) -4.00
'r information is rorrecl. 1 agree to comply with all city and county - PLUMBING
ordinances and state laws relating to
building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter,upon the BOILER-COMP (OVar 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep,I less the City of MISC.- REFER TO ORD. -
pertlno against liabilities,judgments, costs"and expenses which- - CONST,TAX i
in any way accrue against said City in consequence of the PERMIT'ISSUANCE 10.00
r ing of this per m'U MECH,CONT. LIC.NO. MECH.
�'+� g/ TOTAL TOTAL
ig tureof Applica Contractor Date,. - - -
OFFICE COPY