15742 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES = USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION •PERMIT NUMBER
ADrmSc 8A APPLICATION & PERMITADDRESS 15742
BUILDIIN
47
1"n C BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER] PLAN CHECK VALIDATION
L NAME I GTY. ELECTRIC PERMIT FEE
PHONE
r CONTRACTOR'S
nW,E aI -_ ' AAw UTLETS-SWITCHES-RECEP 10.00/1.00
P uC.No. Z'I%VLIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S Ip APPLIANCES'-RESIDENTIAL' 4.00
ADDRESS r
II O' DiL. >HOrvE��/�3 PANELS 10.00 DATE OF APPLICATION
onCXITECT PANELS (OVER 200 AMPI 20.00 PLAN CHECK FEE .NO.
ENGINEER
LIC,NO. SIGNS TRANS. 3.00
ARCHeOR ENG' SPECIAL CIRCUIT 5.00 PER MIT VALI DATION
ADDRZIP TEMP.METER OR POLE INS. 20.00 / A
AAPDRESS s O MOTORS SEE FEE SCH. �j
DDRE55 ����`` � ,
PrCUYq CA-94pz5 SERVICE CHANGE 20,00
o ¢ i IL_
F o o LICENSED CONfRAC1'ORS DECLARATION
a u sFa 1 hereby affirm that I am licensed under provisions of Chapter 9 f. ISSUANCE DATE
N z "' (commencing with Section 7000)of Division 3 of the Business and< fid E BLDG. ELECT. PLG. ME
F w z Professions CoJy aoJ my licenLi is in full fo led. ❑ ❑
z o in - Littnsj fl/ ZOf� Lic.Numtrer, . .
O H o Date Gtr Contmaor
P w _
< , s; BUILDING ar BUILDING PERMIT
¢ < OWNER-BUILDER DECLARATION
o a U INFORMATION
X
g w 1 1 hereby Afifm that 1 um exmnpt from ma Comructors License MISC.- REFER TO ORD
F ¢ a- Law for the followingreason.(Sec.7031.5.Businessand Professions pERM1T ISSUANCE 10.00 VALUATION 9/FT.
Code:Any city or county which requires a permit W construct.alter,
or G p improve;demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- DLL requires the applicant for such permit to file a signed statement that - TOTAL PERMIT TO
E
9 he is licensed pursuant to the provisions of the Contractor's License
rZi Law(Chapter 9(commencingwith Section 7000)of Division 3 of the O
s T o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ 1 0 the husis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicuit for a permit subjects the applicant to a civil Penalty gLTER-DRAIN&VENT-WATER IEA.) 5.00
of not more than five hundred dollars(5500).1:
❑ 1,as owner of the properly,or in, employees will, wags us BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offend for sale(Scc" 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contraelur's License Law does not apply to an owner of -
property who builds or improves Ihercon,and who does such work FIXTURES,PER TRAP - 5.00 SEE FT.FLOOR AREA TOTAL ACREAGE
es
\ himself or through his own employe ,provided that such improve-
Cents are not intended or offered for Sala If.however,the building GAS-EA.SYSTEM-11NC.4 OUTLETS 6.00
Nor improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
l builder will have the burden of proving that he did not huild or ice- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
` ❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licanicd contractors to construct the pro]ect(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASS15SSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves Theron.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 -
contracts for such projects with u conlruetorts)lice„sed pursuant[o
the Contractor's License law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT No-. PARCEL NO.
❑ l um exempt under Sec ,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dare WATER SYSTEM 5.00 ACC.DATE ACCFILENO.
WORK ERS'COMPF.N'SATION D17CIARATION WATER TREATING EQUIP. 5.00
I-hereby affirm that I have a certificate of cement m self-inulin.
or a cerlifaca le of Workers'Coanpensa on Insurance,or a cerODad ZONING ENG.SITE NO.
copyhenyf�$P��}$Q 0,Lab.C.)'
policy N.A -Colo mpmiyi:4
O Cemil copy is byeby furnished FIRE$PRINK ENERGYT34
Z o I Certs eco is filedd wiNW4 cit/w.tiou division. MISC.- REFER TO ORD. I N� v N4
1A, /�WY.i/ r.OPI'
L2 CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
UJ > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
� Z
(This section need nm he completed if the permit is for one TOTAL v N� Y E_ N�
hurdled dollars(S 100)or ICss.i
U O I certify that in the perfommnce of the work for which this per- GTY. MECHANICAL PERMIT , ' FEE FEE SUMMARY
LL 1- mit is issued, I shall not employ any person in any manner so as[o
U Inco,nc whjcct m tllc Workers'Compensntinn Laws of- ifamiu.
O w Date Applicant ALTER OR ADD TO MECH. 5.00 r_Q BUILDING
} tan NOTICE TO APPLICANT'', If,after making this Certificate of Ex-
r 2 emptiun,you sliould become Subject tui the Workers Compenmtiou APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 1Op000F.M.) 4.00
CONS rRUCrION LENDING,AGENCY AIR HANDLING UNITIOVER 10,000C.F.M.) 6.00 SEISMIC FEE
1 hereby joins [hat here is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performan¢ 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 Namc
Lenders Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I rhruic that el have readree oapplicationoyand state that dcaboveounty VENTILATION FAN (SINGLE) 4.00
infornmtion is orrecl. I agree to comply with all city and county PLUMBING
inch nanem aml state laws "dating to building consmetion. and BOILER-713( Tor100,000B.T.U.) 6.00
hereby authonee representative, of this City to enter upon the BOILER-COMP Over 100,000 BTU)SEE.FEE SCH. MECHANICAL
above,Inen0
tioned p opeNy for inetion .
(We) cc b sive emnifyspc
and purposes
keep harmless the City of MISC.- REFER TO ORD.
uperti i is i judgments, costs and expenses which CONST.TAX
may i a w y against said i� in consequence of me PERMIT ISSUANCE 10.00 .00
°min `//�/ LIC.NO. MECH.
igna u ','•�� 1 TOTAL TOTAL 0 v
ontractor Dale NHW 0
0
OFFICE COPY