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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
I;UG.DING PROJECT IDENTIFICATION
APPLICATION &PERMIT
BUILDING - ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
n
" T 232
VALIDATI N
.OILDING
AODRESo H �f
C.11i
NAME 44
CITY. ELECTRIC PERMIT FEE
RACTOR '.
UTLETS- SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
LIC. NO.
r, rRA R's •- -ss
PPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
Ptetligq I¢
DATE OF APPLICATION
AR ECT
OR
ENGINEER
' uc.No.
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS.: 3.00
ARCH. OR ENG,
ADDRESS
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
TEMP.METER OR POLE INS. 15.00
nv
01,�
ADDRESS -
AOOREss
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00LICENSED
JEDAIE
CONTRACTORS DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 93
ISSUA
(commencing with Section 7000) of Division 3 of the Buss ess and
Professions Clse is in full t •c .
License Class Lic. Nwnber
L G. ELECT. PLG. MECH.
❑ ❑
Ualc Contractor
,
BUILDINGP IT
"
OWNER -BUILDER DECLARATION
I herebyaffirm that I am exempt from the Contractor's License
a P
following reasom(Sec.7iresa emit to codProfessions
Law for Any
Code: Any city or county which requirese permit mconsua c alter,
improve, demolish, or repair any structure, prior to its issuance, also
INFORM TION
MISC. - REFER TO ORD
VALUATION
PERMIT ISSUANCE _ 6.00
ELE ON C. NO.
ELEC.
t Snell Permit ns file a Signed statement that
heQ W(CS IIID dp pursuant
he is licensed Pursuant en the with provisions of the nl ivisios License
D ivision3 and
Law (Chapter 9(commencingwith Section is exempt
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5
TOTAL
P RM T TO
/f , i
OTV. PLUMBING PERMIT FEE
STORIESv
TYPE CONSTR.
by any applicant for apermil subjects the applicant to a civil penaltyALTER-DRAIN&VENT-WATER(EA.)4.00
of not more than five hundned dollars (S50OLL
C1 1. 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 2.00
OCCGRouP
.
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, GOND. 4.00
intended or offered for sale (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 does such work
'
FIXTURES -PER TRAP 4.00
50. FT. FLOOR AREA
TOTAL ACREAGE
himself or through his own employees, provided that such improve
•nts are not intended or offered for sale. If, however- the building
GAS -EA. SYSTEM- 1 INCA OUTLETS 4.00
inpravemem is sold within one year of completion, the owner
der will have the burden of proving that Be did not build or im
prove for purpose of sale.).
❑ 1, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 1.00
BUILDING USE
IND .CON PB other
❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
licensed contractors to construct the project (Sec. 704.4, Business
ASSESSORS PARCEL NO.
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 - OVER 5 (EA.) 1.00
'
contracts for such projects with a commetor(s) licensed pursuant to
the Contractors License Law,
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C. for this
WATER HEATER W/VENT 4.00
son
Dam Owner
WATER SYSTEM 4:00
ACC. DATE
/ ACC. FILE NO.
WATER TREATING EQUIP. ' 4.00
WORKERS'COMPENSATION DECLARATION
1 hereby affirm that 1 have a certificate of co en`to -insure,
or a certificate of Workers' Co sation Iii ¢e, or c tificd
ZONING
ENG. SITE NO.
copy that • 1 cQ A00, Lab.C.
Polic]�No. Company _
FIRE SPRINK
ENERGY T-24
OP Cerh Ie co Is hereb I f nish
P -Certified c p is fi with to city inspection division.
AP
v❑ N
Y❑. NC]Plicant
MISC.- REFER TO ORD.
PERMIT ISSUANCE 6.00-
FLOOD zorvE
AL. u.c.
•
CIiRTIF AT . ' E 'S TJONFROM WORKF,RS'
PLG. CONTR. LIC. No.PLG.
TOTAL
COMPENSATI DNINSURANCE
(This section need not be completed if the permit is for one
Y ❑ N❑
Y ❑ N❑
MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars (S 100) or less.)
I certify that in the performance of the work for which this per -QTY.
mit is issued, I shall not employ any person in any manner so as to
BUILDING
7,C �,L�
become subject to the Workers' Compensation Laws of California.
Date -Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Ex.
sorption. you should become subject to the Workers' Compensation
ALTER OR ADD TO MECH. 4.00
APPLIANCE 4.00
PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
such provisions or this pemlit shall be deemed revoked.
CONSTRUCTION LENDING APENCY
FEE
AIR HANDLING UNIT (TO 10000C.F.M.) 3.00
AIR HANDLING UNIT (OVER 10=C.EM.)5.00
SEISMIC FEE
�f
Fw
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, Cie.CJ.
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATI NGUNIT(OVER 100,000 B.T.U.)7.50
ELECTRIC
Lender's Name
Lender's Address
I Certify that I have read this application and state that the above
information is correct. 1 agree to comply with all city and county
ances and state laws relating to building construction, and
VENTI LATION FAN ISINGLE) 3.00
PLUMBING
BOILER- COMP H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP IOver 100pGO BTU) SEE FEE SCH.
MECHANICAL
ty authorize representatives of this city Io enter upon the
•-mentioned property for inspection purposas.
MISC. - REFER TO ORD.
CONST. TAX
e agree to save, 'ndemnify and keep harmless the City of
C erti against liabil ies, judgments, costs and expenses which
y in y way acct ag st said City in con Yuen of the
g ming this permit.
pERMIT ISSUANCE 3.00
MECH. CONT. LIC. NO.
MECH.
0TAL
TOTAL
t
Sl ature A plicanl/ ant actor ate
OFFICE COPY