17829 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT 11,
ADDRESc -7 2 178
29
^oZOCO5 / ADEN SID /tDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNERl' PLAN CHECK VALIDATION
nAME Ahr,) Ai'-��
E� OTV. ELECTRIC PERMIT FEE
t�7lt�s PHONE
coNTRACT Rs ✓ OUTLETS 10.00/1.00
N4ME � / f�-
m` LIC.N LIGHTING FIXTURES 10.00/1.00
CONTRACTOR' /
Anon ///L APPLIANCES-RESIDENTIAL 4.00
ES '
4 PHONE PANELS 10.00 DATE OF APPLICATION -'
ORRCHITE PANELS (OVER 200 AMP( 20,00 PLAN CHECK fEE I'.C.NO.
ENGINEER
uc.no. SIGNS TRANS. 3.00
AARCH DDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
Z11 EMP. METER OR POLE INS. 20,00 C Wil _ q
ADDREESS
AMOTORS - SEE FEE SCH. J 1
ORss
SERVICE CHANGE 20.00
o � = --A . wrtL
H
GO LICENSED CON'I'RACfORS DECLARATION 37
o U I hcrcby Allme that I am licensed ander provisions,,f Chapt,,,FHq ISSUANCE DATE
H G ec (commencing with Section 7000)of Division 3 of the Business an BLDG. ELECT. PLG. MECH.
H y i Professions Code,and my liccnw is in full force and effect. `e...
z O - License ClassLic.Number-
0Wf•'I
F a Date _ Contractor ^,yJ �j
a Y ` • - BUILDING PERMIT
Sc BE o OWNER-BUILDER DECLARATION INFORMATION
E:
A H I hereby'infirm that I an]exempt from the Contractor's License MISC.- RE TO ORD
u O ¢ Law for the hollowing reawn.l$cc.]031.5,Business and Professions VALUATION 5/FT.
H _ PERMIT ISSUANCE 10.00 I C
Code',Any city or county which requiresa permit to construct,alter, //--��//--��//��
La a I improve,demol'uh,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. TE C. 12 [.
w st 0 e o quire the applicant for such permit to Gk a signed statement that TOTAL �Q - PERMIT TO
ea he is licensed purwant to the provisions of the Contractor's License
HiQ
Law(Chapter 9(rommeneingwith Section 7000)of Division 3o fine C 1
Business and Professions Coda)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE J L_
t $ the basis for the alleged exemption.Any violation of Section 7031.5 _ STORIES TYPE r CO,NSTR.
a ; by any applicant fora permit subjects the applicant to a civil penally ALTER-DRAIN& VENT-WATER (EA.) 5.00 - V'�I
- of not more than five hundred dollurs($500)J:
❑ I,as owner of 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 stnrcmre is not
intended or offered for sale (Sus. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 _7s
Code The Contractor's License Law does not apply to an owner of L
property who builds or improves thereon,end 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- � r /' n
menta are not intended or offered for sale.If,however,the budding GAS-EA.SYSTEM-11NC.4OUTLETS 6.00 IGJCa=I
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 IEA-.) . 2.00
builder will have the burden of proving that h - . -
e did not build or inn BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 �/O ❑R IND N ED❑ Other❑
❑ L m owner of the property,he exclusively contracting with
licensed contractors to a Contractor's
ontrtthe project(Sec. does Business LAWN SPRINKLERS-1 INC5 V.B. 6.00 'ASSESSORS PARCEL NO.
and Profession Code:The Conbuilds s License law doss not apply
ca an owner of property who builds to impros i ensed p,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
rant rads for such projects with a contnetodsl licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200D/1 0.00 TRACT NO. PARCEL NO.
O lam exempt under sec. ,H.&I'.C.for this WATER HEATER W/VENT 6.00
awn
Owner [)air WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to Self-insure. pp ZONING
or a certificate of Workers'Compensation Insurance,or a certified J ENG.SITE NO.
copy lbereof(Sec.380Q ub.0 I
Policy No. C t `any
O ❑ Ccrtiticd ropy etch lents FIRE SPRINK ENERGY T 24
p A❑Ilene ificd co is Elcd w' h y irea•di division. MISC.- REFER TO ORD. � v � - N� v � N�
CC CER FICATEOF EXBMPTIONFROM WORKERS' PERMIT ISSUANCE 10.00 ��� FLOODZONE A.L.U.C.
W CONIPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG. JIq (J Y N Y N
� Z Illus Seel ion need not he completed if the permit is for one TOTAL "1
hundred dollars IS 1001 or Icss,)
U O 1 certify that in the performance of the work for which this per- GTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H but issued,1 shall not employ any person in any manner w US to
O w become subject to the Workers'Compertution Laws of Califomiu.
y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING E7,
} m NOTICE '1'0 APPLICANT:.11,after making this Certificate of Ex-
F ? emption,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the labor Code, you must forthwith comply with FEE
U such provisions or this pemsit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M) 4.00
CONSTRUCI'IONLENDINGACENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE ger
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which the permit is issued(See. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lenders Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's AJdress ELECTRIC
I cortily ]hat I have read this application and state(hu(the above VENTILATION FAN (SINGLE) 4.00 1,infonnution fix correct. I uove to comply with ell city and county PLUMBING 4q '
ordinances and state laws relating to building construction, and BOILER-COW(3 H.P.or 100,000 B.T.U.) 6.00
above mentioned
representativestfoinspection
of this city es enter upon the BOILER-COMP (Over 11X),000 BTU)SEE FEE SCH. MECHANICAL4
hereby authorize
properly forinspection purposes.
(We) agree ve, indannify", keep harmless the City'of MISC.- REFER TO ORD. '�7�
upertino a Babitities,judgments, cons and expenses which CONST.TAX
ay in u y accrue pgai said City in conn nce o,the PERMIT ISSUANCE 10.00 I a'JDCJ o(. /
renin lis pem]i / MECH.CONT. LIC.NO. MECH. '
TOTAL TOTAL ^
amre of AppbcanV ontmctor
Daif
OFFICE COPY