13568 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LD04PROJECT IDENTIFICATION PERMIT NUMBER
aDILDING �J/n APPLICATION & PERMIT 13568
AD R a.l C�A/`-.�J�
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
CITY. ELECTRIC PERMIT FEE
PHONE
CONTRACTOR
NAME OUTLETS-SWITCHES•RECEP 10.00/1.00
Lo LID.ND. oL
LIGHTING FIXTURES 10.00/1.00
NTR TOR - APPLIANCES-RESIDENTIAL 4.00
ADDRESS �f p �y�xh/
.9� s 6? 1jW PHONE SV V/ PANELS 10.00 DATE OF APPLICATION
ARCHITECT ' m PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR r2o
ENGINEER , -
LIC.No, ISIGNS TRANS. 3.00
ARCH,OR ENG' SPECIAL CIRCUIT S.QO PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
• - � SERVICE CHANGE 20.00 �yy ��
wo 2 LICENSED CONTRACTORS DECLARATION N,'
c u u 1 hereby air..othat I am licensed under provisions of Chapter 9 ISSUANCE DATE
a z. w (commencing with Section 7000)of Division 3 of the Business and F D 2 Professions C \�W license Is In fVll fu f ILOO. 'ELECT.' PLG. MECH.
o 0 m Licenu Cla CC Lic.Number ❑ ❑- ❑
Date Contractor
+nf �Sf BU4b Ey�d1§PERMIT
a tC w u WN:R-BUILDER DECL
VAT INY'�RMATION
E
3 u y 1 herebyaffirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
' P VALUATION S/FT.
rL04 Law for the following reason(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
w0 J Code:Any city orcounly which requires a permit to construct,alter,
a2 Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
A. O u requires the applicant for such permit to file a signed Statement that TOTAL PERMIT T
whe is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000)of Division 3 of the -
a Bus iness and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
H $ the basis for the alleged exemption.Any violation of5ection 7031.5 STORIES TYPE CONSTR.
w. by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ 1,as owner of the properly,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,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
• properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP S.00 SO.FT.fLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-1INC.4 OUTLETS 6.00
ments are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS•EASYSTEM-OVER 4(EA.) 2.00 BuuOmG USE
builder will have the burden of proving that he did not build or im- . RES IND CON PB Dona,
for purpose of rare.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. . 6.00 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 IEA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to SEWER-SANITAR V•STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ lam exempt under See. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPF-NSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy lhemof(Sec.3800,Lab.C.).
Policy No. Company
-
0 ❑ Certified copy ishereby furnished. _FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection division. MISC- REFER TO ORD.
Q Applicant Y❑ N❑ v E] NE]
~ y
Lu CERTIFICATEEXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.D.c.
COMPENSATION
E.
W � COMPENSATION INSURANCE PLG.CONTLIC.NO. PLG.
1 O (This section need not be completed if the permit is for one TOTAL Y❑ IN Y❑' N❑
Z) Z hundred dollars($100)or less.)
U O I certify that in the performance a work Inch this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL )- mit is issued,I shell not employ a rson' manner so as to
U been a Workers'C msaC aws of Ca ifornia.
w Date �((aa}}. Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>• y NOTI A LICANT: If,1WeM1kir1e'thFT7crtifie1Im of IIx.
H ? en ion,,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 10 QF.MI 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT I C.F.M.16.00 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. HEATING UNIT(T_OI,100,000 B:T:I'l.) 8.00 . •� MICROFILM
3097,Civ.CJ.
Lender's Name H EAT[NG UN IT(OV ER 100,000& 9.5.10 ELECTRIC
Lender's Address
• 1 certify that I have read this application and state that the above VENTILATION F,�'�}IS'1 ' 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and slate laws relating to building construction, and BOILEfl-COtvIP 13 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,0008TU)SEE FEESCH. MECHANICAL 0�
above-mentioned property for inspection purposes.
(We) a ec;to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cuperlivroinstfittylities,judgmen sls and expenses which CONST.TAX
may i Ry waV true Vgam,�Iy in consequent of a PERMIT ISSUANCE 10.00granoflhis ut. �I/ MECH.CONT. LIC.NO.� TATA4 4Z, • TOTALe o p ant/Co U e ^�`/-s O(/
/ OFFICE COPY