17822 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
BUILDING PROJECT IDTENTIFICATION APPLICATION & PERMIT - 1�/� ^/�
BUILDING 1 / TVS G G
AOOREu 1 1 LDING-ELECTRICAL-PLUMBING-MECHANICAL
20Ca r� C SI KC
NAME 9 ' A �DW.^� PLAN CHECK VALIDATION
NAME E-L` �C-. ---7q� �-1
TIS /sem-J� 6TV. ELECTRIC PERMIT . FEE
ONE 7
CONTRACTOR'S
NAUE UTLETS
-
SWITCHES-RECEP 10.00!1.00
Lie.NO. LIGHTING FIXTURES 10.00/1.00
EONTRACTOR�/ PPLIANCES-RESIDENTIAL 4.00
ao RE55 C!� '�1Y$�/f
PHONE r,%/ PANELS 10.00 DATE OF APPLICATION
OR
ITECi PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
- uc.No. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT S.00 PERMIT VALIDATION
AErDEztv EMP.METER OR POLE INS. 20.00
AvvuCANr's - MOTORS
ADDRESS SEE FEE SCH.
SERVICE CHANGE 20.00 IOC
r Foo LICENSED CONTRAROR$DECLA D 1N �I 3rI � '�yaxG'II�A 'I�lf�fV"J
a i w I hereby a1Lnn Ilial ant licensed under Psn Is fl •J�x�ISSUANCE DATE
(commencing with Section 7000)of Division 3 o the u mess and
BLOG. ELECT. PLG. MEC .
r N z Professions Cale,and my license is in full force a f -
Zo i w p License Class Le.Number _ F FW
r Date. Contractor
m J OWNER-BUILDER DECLARATION DATE BUILDING PERMIT
o a S INFORMATION
X ; LL N I hereby affirm that I am exempt from the Com forter's Licenu - REFER TO ORD /-,
.. O J law for the following r...on.(Sec.7031.5:Ra,mecaand Professions PERMIT ISSUANCE r ,IID, Irlp 70.00 I q_ VALUATION OU S/FT.
� - 0 Cale:Any city or county whichrequitesa permit tocomcurt alter, -
¢ RQO improve, or repair any structure,prior to its issuance;also ELEC.CONTR. LIC.NO. ELEC. ^/j��
O a, requires the applicant for such pemtit to file a signed statement that _ TOTAL `I_I PERMIT TO
w he is licensed pursuant to the provisions of Ills Contractor's Lieense
rai
Use(Chapter 9(commencing with Section 7000)ofUivision 3 ofthe
a business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r g the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to,evil penaly .
of not more than five hundred dollars($500),): 1ALTER-DRAIN St VENT-WATER (EA.) 5.00 >�_�
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEV ICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business unit Professions. DRAINS-FLOOR,ROOF,AREA,COND. 5.00 r,-3 '
Cale'fhe 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.
ments are not intended or offered for sale l L 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 11 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON Pg Omer
prove for purpose of sok.). INDUSTRIAL WASTE INTER. 30.00 Il 1:1 El El El
❑ I,as owner of the properly,um exclusively contracting with
licensed contractors to construcl the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 .ASSESSORS PARCEL NO.
and Professions Code:I he Contractor's License Low don 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 crit ruclops)licensed pursuant to
the Contractor's L"actie Law. SEWER-SAN EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC DATE ACG FILE NO,
WORK ERS'COM PENSAI ION DECLARATION WATER TREATING EQUIP. 5.00
.I hereby dfimo that I have a certificate of consent to self-ins re. ZONING - ENG.SITE NO.
or a certificate of Workers Compemanion Insurance,or a certified
copy thereof(Sec.3800,Lah.C.).
Policy No. npany
Q ❑ Caridad cop hereby furnished. FIRE SPRINK ENERGY T 74
Z z ❑ e nine Y is rnep a the ty imperi II division.
w I MISC.- REFER TO ORD.
O. Applies t V � N0 Y NEI
rat ,PERMIT ISSUANCE 10,00 I A - FLOOD ZONE A.L.U.a
Lu - CI: 114CCOM E SATIO TINS FROM WORKERS'
W � COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
(Thi. .,tiop need not be completed it'the Penni( 6 for ane TOTAL '-(� Y❑ N Y ❑ N❑
hundred dollars($100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
W I- mil is issued,1 shell not employ any person in any manner w as m
Ow become subject to the Workers'Compansut ion Laws of California. n�
d Date Applicant TO MECH. 5.00 BUILDING
} N NOTICE;TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD CJL
F" Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 .PLAN CHECK
prisions of (lie Labor Code, you most Gmhwith.comply will! -�
U
such provisions or this permit shall to deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M,) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.).6.00 SEISMIC FEE _g
1 hereby aI`Fou that Gore Is a construction landing agency lot EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Cie.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 �-
1-ender's Name H EATI N G UNIT(O V ER 100,000 B.T.U.)9.50 AO
I)
Lender's Address E LECTR I C
1 certify that I 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 4C
ordinances and state laws relating to building construction, and BOILER.CQIVPM H.P.or 100,000 B.T.U.) 6.00
hcrcby authorise representatives of this city to alter upon the BOILER-COMP m (Oxer 100,000 BTU)SEE FEE SCH. MECHANICAL 4q�
above-mentioned property for inspection purposes.
(We.) agree t ve, indemnify and keep harmless the City o MISC.- REFER TO ORD. 7
aperlino a liabilities,jadPERcnns, costs and expenses which CONST.TAX
may In an ay aecoc agai t said City in can scs nce fit
um PERMIT ISSUANCE 10.00 �.4• /
rennin his peens MECH.CONT. LIC NO. MECH.
TOTALon ��. TOTAL 7
afore of Appicant/Ctractor Dat 4 P7 q,
OFFICE COPY