5151 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
BUIL DI NG PROJECTI DENTI FICATION - PERMIT NUMBER
milil APPLICATION & PERMIT r
ADOREaS `J I I
/fA/Q6is Adg BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S a•:. ".f . ' i. .: ' PLAN CHECK VALIDATION
"AME41`1�• 1 �� HOa
� OTY�: ' ELECTRIC PERMIT # FEES
PNE
CONN.ACTORS UTLETS-SWITCHES-RECEP 5.00/1.00
/'f 00 ILIGHTING FIXTURES 5.00/1.00 '
CONTRACTORS
oR's
ADDRESS _ PPLIANCES-RESIDENTIAL 4.00
/J 9S /QCIL, ,r PHONE .2f_7-7q PANELS 5.00 DATE OF APPLICATION
ARCHITECT J'19 AJ •OSG SIGNS 6.00 PLAN CHECK FEE P.C.NO,
OR C
ENGINEER'
i sec.NO. SIGNS TRANS. 3.00
A78 iss ENG' SPECIALCIRCUIT - '5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
ADDRESS Ta MOTORS SEE FEE SCH. . PkD1 /
SERVICE HANGE 10.00 - I] 1 ;
w o O LICENSED CONTRACTORS DECLARATION - AN A + ��.J//�•S /
<uu I hereby alfirm that 1 am licensed under provisions of Chapter 9 i ISSUA ATE
y N
Z
(commencing with Section 7000)of Division 3 of the Business and p�• 0 a PLG. MECH.
Z H D Z Professions CoQ.c.al«Iry license is in full force and{'ffect Ls,� ❑ ❑ ❑
D i m o license Class 7 Lie.Numbe�rx_�7/I���_�9�.r i
y H w Uale_L•$O_85 Contractor 4�YJ ASN.C��-ff-
_ _
!O. '
a m f < BUILDING PERMIT, p
¢ ¢ ¢ OWNER BUILUIiR DECLARATION ,
Ko.. _ _ - INFORMA?ION'41,
w ;>y I hereby infirm that I am exempt from the Contractor's License MISC. REFER TOO
Hu004 Law for the following reason.(Sec.703 1.5,Business and Professions PERMIT ISSUANCE 6.00 ' yALUATtON S/FT.
,Ai Cade:Any city or county which requires a permit to construct,alter,
is au ¢ p improve,demolish,or repair any Structure,prior to its Issuance.also ELEC.CONTR. LIC.NO. ELEC. ✓JOOV
D LL' requires the applicant for such permit to file a signed statement that TOTAL PERMIT TD
F
2 he.is licensed pursuant to the provisions of the Contractor's License
I- Z> Law(Chapter 9(commencing with Section 7000)af Division 3 of thes " r
a Business and Professions Code)or that he is exempt therefrom and OTYr• ,.PLUMBING PERMIT,, ,p(F,EEri �7
¢ =g the,basis for the alleged exemption.Any violation of Section 7031.5 4 a �' 'eb,' STORIES TYPE CONSTR.
by any applicant for a permit Subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
/
of not more than five hundred dollars(SSOO)f:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2,00 OCC.GROUP RES.UNITS
their Safe compensation,will do the work•and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,ARE&COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
properly w110 builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SQ FL FLOOR AREA TOTAL ACREAGE
himself through his own employees,provided that such improve-
mentsare rcnot intended or offered for sale.If,however.the building GAS-EA.SVSTEM-11NC.40UTLETS 4-00
or improvement is Sold within one year of Completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
It.
will have'the burden of proving than he did not build or im- RE IND CON PB Omar
prove for purpose of Sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ El
❑
❑ I,as owner of the properly am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does nor apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) " 1.00
contracts 1'or inch projects with a cunlraemds)licensed pursuant to
the Contractor's 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
reason
Owner I I Date WATER SYSTEM 4.00 ACC.OATE ACC.FILE NO.
WORK F,RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm tion I have a certificate of consent to sc1&insure, ZONING ENG.SITE NO
or
certificate of Workers'Compaasxlinn Insurance,or a-M.-I
dYWe,Y�17OrSec.3g ,Espy.).
am,unY-E9Jk2es//MSr_TAA9qjC
0 ❑ ('al lifted copy is hereby furnished - FIRE SPRINK ENERGY.TQ4
z Z Celli ftecopy is lily nth rhe city I lion tion.
.G/aJG__YQ MISC REFER TO ORD. Y N Y NEJ
K 0 Apjfliclm�m CERTIFICATE OF EXEMPTION FROM WORKERS, PERMIT ISSUANCE 6.00 FLOOD . . .C.
W COMPENSATION INSURANC17 PLG.CONTR. LIC.NO. PLG. '
Lu Z (This action read not he completed if the permit is I'or one - TOTAL Y❑ N❑ Y❑ N❑
hundred rich ar.($100)or less.)
U O 1 certify that in the performance of the work lot which this per. PTV. MECHANICAL PERMIT FEE FEE,k MMARY„+„ ,f?a)s±
LL I- mit is issued, I shall nor employ any person in any manner So as ns - " ,
OW become subject to the Workers'Compensation Laws of California. t/r3xZ `
Q. Dam Applicant ALTER OR ADD TO MECH. 4.00 BUILDING G✓•�
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
p 2 eruption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Cade, you must forthwith comply with FEE
U such provisions or this permit Shall be deemed revoked. AIR HANDLING UNIT(TO 101000C.F.M.) 3.00
CONSTRU(,TION LENDING AGENCY AIR HANDLING UNIT(OVER 10PWC.F.M.) 5.00 SEISMIC FEE a�G
I hereby aRum that there is a construction leading agency for EXHAUST HOOD(WITH DUCT) 2.00
rhe performance of the work for which this permit is issued(Sec. MICROFILM /
3097,Civ-CJ. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's AddrHEATINGUNIT(OVER100,000B.T.U.)7.50 ELECTRIC 'S
ess
Icertify that l have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
information is correct.1 agree to comply with all city.and countyPLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100.000 BTU)SEE FEE$CH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cu ertino .hat.liabilities,judgments, costs and expenses which CONST.TAX
Y i way accrue against Said City in consequence of the PERMIT ISSUANCE 3.00
G f t CH.CONT: LIC.NO. MECH.
TOTAL _TOTAL 6S�O
i r o p lea; onlrector Dat
OFFICECOPV