11016 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
aooREs `, � UILDING-ELECTRICAL-PLUMBING-MECHANICAL 11016
OWNEry:� PLAN CHECK VALIDATION
NAMEI\/�._\\A r Vl V. ELECTRIC PERMIT FEE
QnD$�'� PMONE �
CONTRA oR
(V11 NAME WlUTLETS-SWITCHES-RECEP 10.00/1.00
� �/� ,�'V LIGHTING FIXTURES 10.00/1.00
CONTRACTOR S PPLIANCES-RESIDENTIAL 4.00
ADORES ]
e NON / PANELS 10.00 GATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 111' V
APPLICANT'$
ADDRESSMOTORS SEE FEE SCH-
OREss
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION n / f
rt is 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w G n (commencing with Section 7000)of Division 3 0f lh Basin n BLDG. ELECT. PLG. MECH.
r N z Professions Code,and my license is in full to a ec ❑ ❑ ❑
Z,z W o License Cla Lia Number -
r y f J Date �-(/J�-{��E�-���--Contractor
BUILDING PERMIT
¢ a OWNER-BUILDER DECLARATION
a o> O INFORMATION
w 3 I I- 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION 3/FT.
FuoU. a Law for the following reason.(Sec.703 L5,Businessand Professions PERMIT ISSUANCE 10.00
vi Code:Any city or county which reyuiresa Permit to construct,alteq
rt2 Q Q improve,demolish,or repair any structure,prior to its issuance,also FLED.CONTR. LIC.NO. ELEC. _
DLL requires the aP,frmu:for such permit to file a signed statement that TOTAL
K
m he is licensed pursuant to the provisions of the Contractor's Licenseyyyy���� RMIT
Uzi Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe �LB�
z o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
Ix I- o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ;m by any applicant for a Pemtit subjects the applicant to a civil penally ALTER-DRAIN -WATER (EA.) $.00
of not more than five hundred dollars(S500).):
❑ 1,as owner DO the property,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 (Sea 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,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-
mentsare not intended oroffered 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 owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or am. BUILDING USE
prove for purpose of sale.). RES IND CON PB Other
❑ I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ ID ❑ ❑ ❑
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(EA.) 1.00
contracts for Such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200f,11 0.0 TRACT NO. PARCEL NO.
❑ tum exempt under see ,B.&P.C.tin this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPRNSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure,
or cc Ica of W kers'Compeasaf I `��rwe�e�o�c}epr�i f¢I A LL Nza� - p ZONING ENG.SITE NO,
n Wv-
pny_
❑ ertifled o i her y fun she 0Z C) ClCertified is fit wi h Ofi sped n ivision. FIRE SPR INK ENERGY T24
1-- O Applicant _ . MISC.- REFER T D. Y ❑ N❑ v ❑ NE]
C rn CFRTI ICA EOF E . PTI N FROM WORKERS' PERMIT ISSUANCE CI Y 10,00 a FLOOD ZONE A.L.U.C.
L C MPIiNSAT10N INSURANCE PLG.CONTR. LIC.NO. PLG
CL O (This sectio, ed not be completed if the Permit is for one TOTAL ( YE] N v ❑ N
0 Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTYMECHANICAL PM
LL 1- mit is issued,I Shall not employ any person in any manner so as to PERMIT FEE FEE SUMMARY
U become subject to the Workers'Compensation Laws of California.
Do Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F ? mprvisions of the Labor Code, you must forthwith comply with nption,you should become subject.to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
V sucoh provisions or this Permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MIC.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10XIMCEM.) 6.00 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. MICROFILM
3097,Civ.0 L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Nam,
Lender's Address HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct.1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 1h W
hereby authorize representatives of this city to enter upon the BAILER-COMP(Over 100,000 BTU)SEE FEE SCH.
above-mentioned property for inspection purposes. MECHANICAL
(We) agree to save, indemnify and keep hornless the City of misc.- REFER TO ORD.
C crone, again liabilities,judgments, costs anJ expenses which PERMIT ISSUANCE 10.00 CONST.TAX
a in any w;} accrue against said City consequence of tire
an 'ng f t is mit. MECH.CONT. LIC.NO. MECH,
( L OTAL TOTAL
go ire pplicarl/Con ctor ate Or
OFF CE C PY