17841 (2)- APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION - PERMIT NUMBER
Boo-DING APPLICATION & PERMIT :ajg1 I]O /� 1
ADDRESS I I O
PZ I -t-' O l BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 4
I
ONrv¢R's PLAN CHECK VALIDATION
NP1AE �-nsla�� {2-�� QTY. ELECTRIC PERMIT FEE
coNTRAc R UTLETS-SWITCHES-RECEP 10.00/1.00
NAME /
LIC.NO, LIGHTING FIXTURES 10.00/1.00
r,ONTRACTon /^ APPLIANCES-RESIDENTIAL 4.00 4
ADDRESS `(a
OR
PRGNE - PANELS 10.00 DATE OF APPLICATION ^
RCHI CTIPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE .C.Nv.
ENGINEER .
LIC.NO SIGNS TRANS. 3.00 -
ADD.ESsena SPECIAL CIRCUIT 5,00 fPERMIT VALIDATION
zlp EMP.METER OR POLE INS. , 20.00 '��I(�•--�a'
ASNr'S MOTORS SEE FEE SCH.
DA"LICDHEA 0.Y
SERVICE CHANGE /�� 20.00
0 0 0 LICENSED CONTRACTORS DECLARATION _AlQ 37
G v w I hereby alliin that I n IlcxnseJ c al1�f( pl ISSUANCE GATE
n
(commencing with Section 70001 of unsi 1 'B s
y /�1 4 IJ LOC. LECT. PLO. MECH.
F N z 1'rofessionS Codc,and my lien.is in for nd r(1' L 1'Is�
z o m - License Clau Lic.N
a w r w Dam CDnto
a K s � t 2 City of rimOrtino BUILDING PERMIT
w�- OWNER-BUILDER DEC�Q{� u INFORMATION
s O a t 'flfC% - REFER TO ORD
w 3 LL H I hereby Alirm that I am excglpl from 1 - VALUATION S/FT. -
FLOa Law for the followingrcawn.(Sete-7031.5,BusinessandProfxUons PERMIT ISSUANCE 10.00 ��^ d7
Code Any city or county which requires a lietmil to contract,alter, Ln
2 ¢ a0 improve,demolish,or repair uny.structure.prior toils ixtaanCe,ale ELEC.CONTR. LIC. ,/ )c
ELEG.
O , requires the applicant for well permit to file a signed statement that TOTAL q PERMIT�TO
waw( apter (commencng wSection )ni
he u licensed pursuant In the provisions of the Contractor's License
i x.01 ✓W
H z LCh9iith Si7000 'Division 3 ofthu
a Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
A f S the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
u, by any applicant for a pcmlii SubjeCIS the applicant to u civil penally ALTER-DRAIN -WATER IEA.) 5.00
of not more than Five hundred dollars($500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sale compensation,will do the work,and the structure is not n`x
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Codc The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who dues such work FIXTURES-PER TRAP 5.00 sa FT.FLOOR AREA //TOTAL ACREAGE
himselfornot hrough
ownemployees.for
ssle If,however,
the building
GAS-EA.SYSTEM-1 6.00 /�y� `'fs)
meats are nor intended or offered for sale.If,ed that s the building ; f�//
or improvement is cold within one year of conlplctlun, the owner- GAS-EA.SYSTEM'-OVER 4 (EA.) 2.00
builder will have the burden cf proving that he did not build or im. BUILDING USE
prove for purpose of sale.). USTRIAL WASTE INTERREs IND CON Pe Other
❑ 1,as owner of the properly IND . 30.00 um exclusively contracting with �❑
licensed Contractors to construct the project(Sec. 7044.Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORSPARCELNO-
and Professions Code:The Contractors License Law dues not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts forvuch projectswirh a coinctons)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ am uxcmpl under See. .H.&I'.C.for this WATER HEATER W/VENT 6.00
lemon
Owner Date WATER SYSTEM 5.00 ACO.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a en Reale of consent to sclGimure. r�--TONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Se,3802 gTb.C.0 -
Policy No, pony -
O ❑ Certified cop' s�Ereby furnished FIRE SPRINK ENERGY T 24
Z Z ❑ Certified c n filed w' the y inspecti division.
O App bunt / �I MISC.- REFER TO ORD. q Y � N� Y � N�
Qy FICA I'Ii OFIi :8 I NPROM WORKERS' PERMIT ISSUANCE - 10.00 �"� FLOO)ZONE, A.L.UO.
L,> COMPENSATION INSURANCE PLG.CONTE. LIC.N0. PLG
CL . A(� O� Y N Y N�
O (This section need not be completed if the permit is for one _ TOTAL aY 1
Z) 2. h u n d red doll am(S 100)or less.) r
U O I certify owl in the pedoon,nce of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,1 shall not cmpbay any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
i Dam Applicant ALTER OR ADD TO MECH. 5.00 BUILDING -
}'w NOTICE TO APPLICANT: IL after making this Certificate of Ex-
F I? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions set' the Labor Code, you must kolhwith'comply with FEE -
(� such provisions or this permit shall be deemed revoked AIR HANDLING UNIT TO 10=CF.M.) 4.00
CONSTRUCT ION LI"NDING AGENCY AIR HANDLING UNIT(GVER 100MC.EM.) 6.00 SEISMIC FEE 833
I hereby affirm that there is a namandion lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of tlm work far which this permit is iseucd Nee. MICROFILM
3097.Civ.C.0 HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT IDV ER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC A/1
1 certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00 r
;. information is.correct. I agree to comply with all City and county - PLUMBING
ordininecs and stale laws relining to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city In enter upon the BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
ba _
ase-mentioned properly'for inspection purposes. -�
(We) agree to 'vo, indemnify and keep barmy the City of MISC.- REFER TO ORD. , '/'
uperlino agar (abilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 .i2• CONST.TAX /2 4
may in any accrue agar t thud City in co Iuenc of the s TTT
lia�nn lag Is perp, MECH.CONT. UC.NO. MECH.
TOTAL An D� TOTAL f,
ature of ApP can[Contractor Date
I / �1
OFFICE COPY