17990 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES .- USE BALL POINT PEN ONLY
BUILDING PROJECT I DEI F I CATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 17990`J^O
- A "jB b DOLOR ENt}E
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL `J
OWNER'S PLAN CHECK VALIDATION
NAME
1'10 �v��j C�Q6 Yj QTY. ELECTRIC PERMIT FEE
}{ ` vHONE
CONTRACTORS
' N E �! ^ Q•C UTLETS-SWITCHES-RECEP 10.00/1.00
i - - � IC NO (J✓ LIGHTING FIXTURES 10.00/1.00 �YL 7�(�l
CDNTRACiolrs PPLIANCES-RESIDENTIAL 4.00
AOOR Ess_ F) ^^
1 V 1 Je PHONE PANELS 10.06 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO"
OR PANELS (OVER 200 AMPI 20.00
ENGINEER �k' 1 (,� ''J
I'1\N ie.No� 7 TI SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ARCH,O ` y,� LfIeJ] SPECIAL CI RCU IT 5.00
✓O COM. zlr EMP. METER OR POLE INS. '20.00
ADDRESS MOTORS SEE FEE SCH. J l
2 ADDRESS ,^D/'� �•�, �'M
q ObL k..F65 / YV PV\T SERVICE CHANGE 20.00
j o
FDD LICHNSEU CONTRACTORS DECLARATION .113 V
r x u u I hereby allium that 1 ant licensed under provisions of Chapter 9
G 2 w (commencing with Section 7000)of Division 3 oI'III,Business and A�- ISSUANCE DATE
G < H SLOG. ELECT. PLG. MECH.
F N z License Ch Code,and my iccnsc iv in full forty:mJ c'fccf.
License Class Lie Number
Date Cnntracwr / 4
F - a ® 6VIPEJ
s Q W a OW'NF.R-BUILUIiR DECLARATION BUILDING PERMIT
1 Joao INFORMATION
w ;LL F 1 hereby infirm that I am exempt from the COWTUclofa License - EFER TO ORD
F u D j Law for the following reason.(See.7031.5,Businessand Professions 10.00 ,\ VALUATION S/FT.
Code:Any city or county which requite,a permit to construct,alter, � oo
Q O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NQ ELEC. U (J
DLL requires the applicant for such permit to file a signed Statement that TOTALCI I, 6- 3 PERMITTO
Ill ' w m he is licensed pursuant to the provisions of the Crntruc(oh License
F Z a
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
i o Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE F,-
R H m the basis for file alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant HIS civil penalty
I A ' - of not more than five hundred dollars(55001): ALTER-DRAIN&VENT-WATER (EA.), 5,00
❑ 1,as owner of the property,or my employees with wages BACK FLOW PROTECT. DEVICE 4.00
V their sole cuntpemm�on,will do the work,and tlm stnmture is not DCC.GROUP RES.UNITS
1_ intended or offered for sale (See. 7044, Business and professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor',License Law docs not upply 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-
ments are not intended or offered for sale If,(however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00 3 6 � 1-.../ 70
or improvement Is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or ins- BUILDING USE
ove for Purpose Df salcJ. RES -IND CON PB Color
'I,as owner of the property,ane exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
"ensed contractors to construct the Pr jCCI(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's Licensc Law does not apply
to an owner of property who builds or improves and who LAWN SPRINKLERS-OVER 51EA.) 1.00
1 contracts fursuch projects with a co mctorQ ud pursuant w
(` the Contractor's License La SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ Iwnv r ,e.&I'.C.for this
reason WATER HEATER W/VENT 6.00
J - _
r Ow'ne _ [)at - WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORAERS'COMP1'NSA I'ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of mmsgot to wif-insure.
tor a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
p copy fhereuf(Sec.3800,1ab.C.L ,
II
Policy No. Company
O ❑ CeRilicd Copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z o anrtilicd copy is fled with the city in.vpaction division. MISC.- REFER TO ORD.
( O ApPlic:utl y ❑ N Y ❑ N❑
CFR'1'II:ICATG OI'EXEMYPION FROM WORKIiRS' PERMIT ISSUANCE t- 10.00 Ed
I > COMPENSATION INSURANCE PLG.CONTR. LIC:NO. PLGd C (This rection need not be completed if the penin( is for one TOTAL v❑ N❑ Y ❑ N❑
D Z hundred dollars IS 100)or Ies%.)
U 0 1 certify that in the performance of the work for which this per- DTY. MECHANICAL PERMIT FEE FEE SUMMARY
I H mi( is issued,I shall not employ any person in any manner so as to
U W bewmesubjeo(a the Works Cn In......tion Laws of California.
n Date Applicant ALTER OR ADDTO MECH. 5.00 BUILDING /h`.�fl
} N Date Ii 'fD AI'I'L A.plica I(,utter making thiv Ccrt ilicutc of
Z emplion,you should become subjeCt m)the Workers'Compensation
F- - APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, YOU must forthwith comply with -
U such provi%ion%or this permit shall he deemed revoked. I AIR HANDLING UNIT(TO 10=1C.F.M") 4,00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.RM.) 6.00 SEISMIC FEE e�
1 herehy 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. MICROFILM
3097,Civ.C.), HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UN IT 100,000 B.T.U.)9,50 O
Lender's Address - ELECTRIC
I certify that l have read this appllcafiom and s,ate(hat 1thc above VENTILATION FAN (SINGLE) 4.00
information is correct.I agree to comply with all city and county PLUMBING 3
aft ordinancos and state laws relating to building Construction, and BOILER-OM1P(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorlce representatives ot
to enter opo the BOILER-COMP Over 100,000 BTU)SEE FEE SCH. -[
above-mcmioneA property for inspeses, I MECHANICAL
(We) agree fo save, imdcmmitharnle a City of MISC.- REFER TO ORD.'operon. against liabililios a eines which PERMIT ISSUANCE 10.00 CONST.TAX. ��-�
ay in any w ga' SuC quence of the
ranting MECH.CONT. LIC"NO, MECH.
_9a TOTAL Q I 0� TOTAL 7 7
Sig lure of Applicant m Date - / � .I
OFFICE COPY