14663 (4) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
a ' J
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
APPLICATION & PERMIT `
emaDlNc - 1 ACC
'�j AOOREaS I o v
c BUILDING -ELECTRICAL—PLUMBING—MECHANICAL t 4
OWNER'S
NAME PLAN CHECK VALIDATION -
-1( OTV. ELECTRIC PERMIT FEE
PHONE
CONTRACTORS
\/ NAME - - OUTLETS-SWITCHES-RECEP 10.00/1.00
Y Cr4i ASO ua NO4Z C7/1 LIGHTING FIXTURES . 10.00/1.00
CONTRACTOR A ry—
CTORs
�, APPLIANCES-RESIDENTIAL 4.00
^(
J� lJ/J/A C-7PHONE 73 PANELS - 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P;C:NO.
OR - PANELS (OVER 200 AMP)" 20.00
ENGINEER ,
LIC.NO SIGNS TRANS. 3.00
ARCH OR ENG' _ SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDESS
ZIP TEMP.METER OR POLE INS. 20.00 —
APPLICANTS MOTORS SEE FEE SCH. I c �)
ADDRESS Qf ' ` -
Fj0 �uDG SERVICE CHANGE 20.00
w o o LICENSED CONTRACTORS DECLARATION j p
a i I hereby-affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE(commencing with Section 7000)of Division 3 of the Business and
�A<to BLOC. ELECT. PLG. MECH.
H o z Picsaix ions C0" Ind license is in full forced Cfen. ❑ ❑
2 O w - Licens;fla Lic.Number
D Z D DateContractorContractor .
a m ca `� BUILDING PERMIT
¢ o a U OWNER-BUILDER DECLARATION INFORMATION
X ; I- 1 hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD
,.o� Law for the followingreason(Sec..703L5,Businessand Professions VALUATION S/FT.
H _ PERMIT ISSUANCE . 10.00 U—
Code: e,demolish,
county pair any struiresa turep riort oconstrucLalter,
ce M 4 improve,demolish,or repair any structure,prior lD its issuaneo,also ELEC.CONTR. LIC.NO. ELEC.
ce DLL requires the applicant for such permit to file a signed statement that TOTAL MIT
F
PERTO S he is licensed pursuant to the provisions of the Contractor's License '
rzi Law(Chapter 9(commencingwlth Section 7000)of Division 3 ofthe r-/,Q,,,
,a Business and Professions Code)or that he is exempt therefrom unit DTV. PLUMBING PERMIT FEE
H c the basis for the alleged exemption.Any violation oCSection703L5 STORIES TYPE CONSTR.
so by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($500),1:
❑ 1,as owner of the property,or my employees with wages-as BACK FLOW PROTECT.DEVICE 4.00 DCC.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
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintended or offered lot sale.If.however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM.OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that h .e did not build or im- RES IND CON PB Orion
thp
prove for purpose of se 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.
mid-Professious 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 contractorts)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 - TRACT NO, PARCEL NO.
❑ Iamexemptunder Sec, ,B.&P.C.for this WATER HEATER W/VENT 6.00 -
reason •
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby dritan that I have a certificutrof consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,
.orlaa certified
-G copyYhNo I�JCo pant )STt��N�P++.
/ ❑ Certified copy is herehy furnished. - - FIRE SPRINK ENERGY T-24
Z Z Bliemi f• p file 'Ot the city ins ioi rvision.
O� APPlicant� CJ y i,, i,•�ICjL MISC.- REFER TO ORD. v N� v . N❑
~ vi PERMIT ISSUANCE 10.00
� -
CERTIFICATE OFEXEMPTION FROM WORKERS' FLOOD ZONE A.L.u.G.
W COMPF'NSATION INSURANCE. PLG.CONTR. 'LIC.NO. PLG.
Z ('This section need not be completed if the permit is for one TOTAL Y •N� V NE]
hundred dollars(5100)or less.)
U O 1 certify that in the performance of the work for which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
Date Applicant BUILDING d�U
a ALTER OR ADD TO MECH.- 5.00
} rn NOTICE TO shout become
If,ufmr making this Certificate of F:x-
? emptier,you should become suhlem roust forthwit'Ccomply ith APPLIANCE 5.00 PLAN CHECK
provisions io the Labor Code, yo a dee forthwith comply with - FEE'
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LE.NDINGAGENCY AIR HANDLING UNIT(OVER 10=1C.F.M.) 6.00 SEISMIC PEE
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(TO 100,000 B.T.U:) 6.00 MICROFILM
Lender's Name HEATING UNIT 100,000 B.T.U.)9.50 -�
Lender's Address - ELECTRIC OZO
I certify that I have read this application and slate that the aboveVENTILATION FAN (SINGLE) 4.00
information is correct.I agree to comply with all city and county - PLUMBING-
/ ordinances and slate laws relating to building construction,and BOILER-COW H.P.or 100,000 B.T.U.) 6.00 .
hereby authorize representatives of this city to entervupon the BOILER-COMP IOvar 100,000 BTU)SEE FEE SCH. MECHANICAL '
above-mentioned properly for inspection PUTPUScs.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. -
uperline against liabilities,judgments, costs and expenses which pERM1T',ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City {h consequence of the '
Ian in of This pelmil. _ " ji5oeoMECH.CONT. LIC.NO.. TOTAL' TOTAL �j �_
Sig pplica t/Contnc or, Date
OFFICE COPY