18653 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BGILOINGAPPLICATION & PERMIT
AG18653
AGGRESS/,66 Q ^ F
/Ylir` BUILDING -ELECTRICAL-PLUMBING-MECHANICAL i4
GWNER's PLAN CHECK VALIDATION
NAME DeI.H,ia Nei.(,( OTY. ELECTRIC PERMIT FEE
PHONE Z 00
CONTRACTORS• / UTLETS-SWITCHES-RECEP 10,0011.00
LIC.NO. LIGHTING FIXTURES 10.00/1,00
CON TRACTORS N•.,p PPLIANCES-RESIDENTIAL 4.00 xN✓nS�(�L+�.�IA
CON TRA5 LL_ .J C
'HONE'�y y PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C. O.
ENGINEER
LIC.No. ISIGNS TRANS. 3.00
ARCHH.SS OR ENG' SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPucANrs/d (o MOTORS SEE FEE SCH.
ORE
AD
L,S,A SERVICE CHANGE 20.00 n�2"1- n
w00 LICENSED CONTRACTORS DECLARATION -1 ( LV
a u P I hereby affirm Hoar I am licensed under provisions of Chapter 9
a . (commencing with Section 70001 of Division 3 of the Business and BLDG. ISSUANCE DATE
ELECT. I PLG. MECH.
0 D z LicenProfese
CodefI and my License Is in full forge Y_SJ effect. .
9 o G - Date Class_E �O_Lie Numbe�rr_ � f�• J 0 .12f
0 N F w Date Contractor nnlractrr C'.DxC4.�+fiP�glrE- ❑ ❑
a: a OWNER-BUILDER DECLARATION Q'K BUILDING PERMIT
LE arow u INFORMATION
wS A I- I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
I.o Law for ilia following reason.(See.7071.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION f/FT.
Code:Anycity orcounly which requiresa permit to construct,alter.
re
M Q G improve,demolish,or repair any structure,prior to Its issuance,also ELEC.CONTra. LIC.NO. ELEC.
i y 0,
requires Ilse applicant for such pCfmll to file o signed statement that TOTAL PERMIT TO
X set he IS licensed Pursuant to[lie provisions of the Contractors License
FZ >
Law(Chapter 9(commencing with Section 70001of Division3ofthc
a Business and Professions Code)or foal he is excnnpt therefrom and OTY. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of5ection 7031.5 STORIES TYPE CONSTR.
d; by any applicant for a permit subjects the applicant loa civil penally ALTER-DRAIN -WATER IEA.) 5.00
of nor more than five hundred dollars(1500).):
❑ 1,as owner of the properly,or its employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and roe structure is not
intended or offered for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law docs not apply to an owner of
properly 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-
menu are not Intended m offered for sale.If,however,the building GAS-EA,SYSTEM-1 INC.4 OUTLETS 6.00
-�, or improvement is sold within one year of completion,the owneGAS-EA.SYSTEM-OVER 4 (EA.) 2.00 aurkOrNG USE
builder will have the burden of proving that he did not build or it'- RES IND CON PB CO.,
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 Cl IND 1-1❑ 1,as owner of the properly,am exclusively contracting with El 0
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 Conlraclo'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 will,a con(ractods)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under See. .B.AP.C.liter this WATER HEATER W/VENT 6.00
reason
Owner Bate WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-inxlre. ZONING ENG.SITE NO.
or a certificate of Workets Compensation Insurance,or a ecrtified
copy thereof(Sec.3800.Lab C.).
Policy No. Company
Q ❑ Certified Copy is hereby furnished. FIRE SPRINK ENERGY T$4
Z Z JW Cerrific copy is Bled with the city inspection division. MISC.- REFER TO ORD.
I"' O Applicant Y I] N Y ❑ NE]
va �I7{� � PERMIT ISSUANCE 10.00
U) CI!RTI PIC AT'F.OP IiAI IO EXEMPTTON FROM WORKERS' FLOOD ZONE A.LU.C.
W ? COMPIiNSAT'ION INSURANCE PLG.CONTR. LIC.NO.
CL 0 IThis section need not be Completed if the Pernlif is for ora• lawY N� Y No
::) Z hundred dollars 111001 or less.) ��i+��--
U O 1 certify that in the performance of the work for which this per. GTY. MECHANICAL PEU-P ] EE FEE SUMMARY
LL F ...it is issued,I shall nor employ any Person in any nanner mus In '7
Owbecomesubjecl to the WGrkc,v Compemallno Laws of Calif Gonia. BUILDING
G,
Dale Applicant ALTER OR ADO TO MECH. 5.00 ,
N NOTICE TO APPLICANT: If,after snaking this Certificate of Ex-
.
Z emptiom,you should become subject to fire Workers'Compensation APPLIANCE PLAN CHECK
Provisions of tire Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10000GF.M.1 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the 3097,,CieC.j�c< of the work for which this permit is issue)IS". MICROFILM
HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Address
Lender's Address HEATING UNIT(OVER 100,000B.T.U.)9.50 ELECTRIC
I certify Oat I have read this application andstale Ilial the above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all oily end county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-713,H.P.or 100,000B.T.U.) 6.00
hereby authorize representatives of this city Io enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL .CO
above-mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless toe City of MISC.- REFER TO ORD.
uperfino against liabilities,judgments, costs and expenses whicls CONST.TAX
nay in any way accrue against said City in consequence of the PERMIT ISSUANCE 2LQU 10.00 '2,CX)
rantm ffthis permil /� MECH.CONT. LIC.NO. MECH.
'^ O� a Qa,.� 9-27-411 TOTALz1x � TOTAL `l Od
Signature of Applicant/ConiftWr Date
OFFICE COPY