17823 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION PERMIT NUMBER .
EDFmNG y { APPLICATION & PERMIT } 17823
ADDRESS L-) I
I"I UILDING-'ELECTRICAL-PLUMBING-MECHANICAL .'
`D� PLAN CHECK VALIDATION
NAME U.j�.( 1_E^"s��� OTV. ELECTRIC PERMIT FEE
Iia- s���} rl�ty�S PRDNE7334
r°1AMe Ac °Rw//yyvi Z'�� UTLETS-SWITCHES-RECEP 10.00/1.00
sec.No LIGHTING FIXTURES 10.00/1.00
CONTRACTORS n/ PPLIANCES-RESIDENTIAL 4.00
ADDRE§p
PRONE PANELS 10.D0 DATE OF APPLICATION 'I
ORC IT T PANELS (OVER 200 AMP) 20.00 PLAN CHECK PEE P.C.NO.
NGINEER
LIc.No. SIGNS TRANS. 3.00
ADDDREOR
SS ENG' SPECIALCIRCUIT 5.00 PERMIT VALIDATION
2,P EMP.METER OR POLE INS. 20.00 1 t 6
WoDosAMOTORS SEE FEE SCH. -1
DRESS Ess
SERVICE CHANGE 20.00
w0 2 LICENSED CON'I'RACfORS DECLARATION ./' _
a o u 1 hereby affirm that 1 am licemud under provisions of Chapter 9 ISSUANCE DATE
a'T. (commencing with Section 7000)of Division 3 of the Business'and
F w i Professions Code,and my litems is in full force and effect. tL: BLDG- ELECT. PLG. MECH.
z 0 e, - Licenw Class Lie.Number
9 v, r 0 Date Contractor s
a5 -�+ BUILDING PERMIT
tc n OWNER-BUILDER DECLARATION INFORMATION
wN 1 hereby uflirot that I am excerpt from the Contractor's Licenu - MISC.- D
LLoa Law for the following reason, 7031.5.Boonessand Profsmons - PERMIT ISSUANCE 10.00 12 _ VALUATION !F/FT.
� - Code:AnycilyorLvunly which requimsa pcmut tocunslruct,alter,
m � /o ^
Q IF ¢ p I
improve,demolish,or repair any structure,prior to i6 ELEC.CONTR..�, LIC.NO. g 7 �
issuance,also ELEC. C tL
O u requires the applicant for such Pcrtnil to file a signed statement that :J PERMIT TO
a
in m he is IicensN pursuant to the provisions of the Contractor's License
Fzi Law(Chapter 9(commencing with Section 7000)of Division 3 oflhe �.-� `'
Q Business and Professions Code)or that he is exempt therefrom and OTY. �r1
PLUMBING PERMIT FEE �L
I the basis for the alleged exemption.Any viululion of Section 7031.5 STORIES TYPE CONSTR.
n ; _ by any applicant fora permit subjects the applicant wacivil penally ALTER-DRAIN& VENT-WATER IEA.) 5.00 v...�
of not more woe five hundred dollen(my employees
❑ I,vs owner at the property,or my employees rich wages as BACK FLOW PROTECT.DEV ICE 4.00 OCC.GROUP RES.UNITS
their sole r offered
for
will do the work,and the structure is not
Code eJ or offered for safe (Sec. 7044, Business and all
owner of DRAINS-FLOOR,ROOF,AR EA,COND. 5.00 19_�
Code:The hContractor's buildLicense how does not apply to ret uwner al f
property who builds h or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 so.PT.FLOOR AREA TOTAL ACREAGE
himself re through his own cerpinyors provided leve such improve- A�
or improvement
intended orthinoffered yetir .if,howetion the the owner-
GAS-EA.SYSTEM-11NC.40UTLETS 6.00 1587
or improvement is wW within one proving
of liedidlnot the uwner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 v
builder will have the burden of proving that he did not build or ire- BUILDING USE
prove fors owner of the.). INDUSTRIAL WASTE INTER. 30.00 REs IND cool PR Omer
❑ d as owner of the property,he exclusivelyproject
Se contracting ing with LJ ❑ ❑' ❑ ❑
Heenan contractors : a CmItolthe project La 7044,Bu sines LAWN SPRINKLERS-1 INC SV.B. 6.00 asSE ORS PARCEL NO.
and Professions Code:The Conb ucds i License Law does not apply
who
m an owner of property who builds or improvesthereon,pursuant
who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
the C. i for such License
is with a conlractorts)licensed purswm Io
' the Comracmr's Licenu Law, SEWER-SAN ITAR V-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ tum exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner [)ate WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPENSATION D17CLARA'I'[ON WATER TREATING EQUIP, 5.00
I hereby atfirm that I have a certificate of consent to self-insure, ,_ ZONING ENG"SITE NO.
or a certificate of Workers'Compensation Insurance.or a cert ifcJ
tum thereof I.cc.3800,Lvb.C.). -
['olicy No, Party
-
0 ❑ CertiOedcop terehy'fumisheJ. FIRE SPRINK ENERGY T 24
z Z ❑ erlif red c is filed wit he y inspection division.
H O Appli am T MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
Q rn 1 P1CA7E OFIiA:M I ' t n Wo KIi PERMIT ISSUANCE - 10.00 ��--� FLOOD ZONE A.L.U.C.
W� O -
COMPENSATION INSURANCIi PLG.CONTR. LIC.NO. TOTAL I -- v❑ N❑ V❑ N❑
C This section need one he c nn Plemd if lee permit is for one
hundred dollars IS 100)or Ins.)
U O 1 certify that in the performance of the work for which this per. DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mil is issued,I shall not employ any Person in any manner so in 1D
O ° tp
become MIR"l to the Workcrs'ConcnsaImn Laws of-Cua
liforniBUILDING
a Date Applicant . ALTER OR ADD TO MECH. 5.00
} to NOTICE 'f0 APPLICANT: If,after making this CeHifmam of Ex-
F Z emptime.you should become subject to the Workers'Conspenvtion 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 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVEi 10MOC.F.K) 6.00 SEISMIC FEE S
I hereby affirm that Entire is u 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 H EATI NG UNIT(OVER 100,000 B.T.U.)9.50 51 SOS
Lender's Address ELECTRIC _
I coldly Ihat 1 have read this application and mute lbal the'ebove VENTILATION FAN (SINGLE) 4,00
information is correct. 1 Amen Ice comply with all city and county PLUMBING C
ordinances and state laws relating to building construction, and BOILER-COfaP(3 H.P.or 100,000 B.T.U.) 6.00 5�
hereby authorise mpreiamlmives of this city to ecce, upon the
ahove-men Honed pro tyfor inspectBOILER-COMP IOver100,000BTUISEEFEESCH. MECHANICAL 51
rion purposes.
(We) agree a sa in
and keep harmless the City of MISC.- REFER TO ORD.
Jay
pertino ag st�aabilitics,judgments, costs and expenses whichCONST.TAX in en w'y/accru ai rid City In conuyue ee o the PERMIT ISSUANCE 10.00 ' _
neon Perml MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL / Q.
t lure of Applicant/Contractor Date 51
OFFICE COPY