17821 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
ADDRING TI APPLICATION & PERMITIos q �Qn�
171�/'_i_ /xA `'SIS 0j DING-ELECTRICAL-PLUMBING-MECHANICAL
NAMLE RLS �wD L� A. l:. PLAN CHECK VALIDATION
NAME ' w
• ri �s 733- 9[04 TY ELECTRIC PERMIT FEE
orvE
DONTERACTO 's UTLETS-SWITCHES-RECEP 10.00/1.00
ry,,
LIC.NO. LIGHTING FIXTURES 10.00/1.00
CONTRA SS TDRa� IW) nrr/ PPLIANCES-RESIDENTIAL 4.00
N PHONE PANELS 10.00 DATE OF APPLICATION
ORRCH ECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC,NO ISIGNS TRANS. 3.00
ARCH.OR ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ADDRE6$
APD IESIs MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
wo o LICIiNSED CONTRACTORS DECLARATION m1mal
a u I hereby aft on that I am licensed under provisions of Chapter 9 - ISSUANCE DATE
"' (commencing with Se Iran 7000)of Division 3 of the Business and
Ci < w 6LOG. ELE T. PLG. MECH.
R O z Pralessions Code,and my license is in full force and effect. - \1L�yLLpy
z IVI
o�- License Choi Lie Number
9 z o Date Contractor ^x
a r E J `' ' BUILDING PERMIT
ma OWNER-BUILDER DECLARATION
w D INFORMATION
ril
K
;?A'- 1 hereby d inm that I am exempt from the Contractor's Licerrse C.- REFE O ORD
a o a Law for the following reason.(Sec.7031.5,Buslnessxnd Professions PERMIT ISSUANCE 10-00' vnLugnoN S/FT.
I - Code:Any city orcounty whichmquiresapermit toconstruct,alter, /'y^�j�
6¢ p improve,demolish,or repair any.stricture,prior to its issuance,slsu ELEC.CONTR, LIC.NO. ELF C ,{/1 O `I 9 V..JL 1
u requires the applicant for such permit to file a signed statement that TOTAL /'t-I I PERMIT TO
A w$ he is licensed pursuant to the provisions of the contractor's License
Law(Chapter 9(commencingwilh Section 7000)o'Division 3 o flhe
a Business and Pro&cions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
M F the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
A 3 by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars($500).L ALTER-DRAIN&VENT-WATER (EA.). 5:00
❑ I,as owner of the property,or my employs with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions Code: DRAINS-FLOOR,ROOF,AREA,COND. 5.00 j(l_3
CodThe Contractor's Lfcenw Law does not apply to an owner of 11��
property who builds or improves thc¢on,and who docs such work FIXTURES,PER TRAP 5.00 SO,ET rLOOR AREA TorAL ACREAGE
. mems aor m not
owneferedfrs provided evTsuch improve- GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00 it l�`h
improve-
ments ase not intended or offered for year
o If,however,the building `?a.-)L
or improvement will have
is e b within one yew that
he did not,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or ire RES IND CON Pa Omer
prove 1,as ownerose
of the.l. INDUSTRIAL WASTE INTER. 30.00 ,V
❑ d as owner of the property,am exclusively contracting with 'Lf� El El 0 ED
licensed csions ors to The
the project(Sec, 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The who
Unite,t License Law Joos not apply
co on owner of property who builds to improves Thereon.swho LAWN SPRINKLERS OVER 5(EA.) 1.00
m
contracts for such projects with a coraetor(sl licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. e' � TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00 -
mascm
OwnerDole WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMI'IiN'SATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of conunl to sal&insure. �1
or a certificate of Workers'Compensation Insurance.or a certified 'J ZONING ENG.SITE NO.
copy thereof(See.3800,Lab.C.).
Policy No. Cyr any
-
0 ❑ Cenilied copy S hereby furnished.
FIRE SPRINK ENERGY Tod
Z Z ❑ Certified co is file&with cit inspection di 'cion. MISC.- - REFER TO ORD.
p APPI.ant �/,,/�/'/�[�,�//�y�� Y N❑ Y [] NE]
Hy 6Nt PERMIT ISSUANCE 10.00 ��11 FLOOD ZONE q.L.u.c.
CC A 'EOPF:%EA 'R )RKIiRS' IIX
EU > COMPENSATION INSURANCE. PLG.CONTR. LIC,NO. PLG. A�)
0- Cl IThis section need not be completed i,,the permit u for one TOTAL 4- I O Y� N� Y� N�
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,1 shall not employ any Perim in any manner so as to
U
become subject to the Workesi Compensation Laws of California
a Dam Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE TO APPLICAN'C If,after making This Certificate of Hx-
H ? crept ion,you should become subject to 0m Worker.d Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONS']'RUCTION LENDING AOBNCY AIR HANDLING UNIT(OVER JOSMCF.K) 6.00 SEISMIC FEE ' - U
1 hereby affirm that there is a construction Icndlng 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 HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC AVI
1 unify that I have read this application and state that he above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and county PLUMBING 4q Q�
ordinances and state laws relating To building construction, and BOILER-OOPIP I3 H.P.or 100,000 B.T.U.1 6.00
above
herby aullmrim Hpresentor of lbs city to soler upon the BOILER-COMP (Over10QIX10BTU)SEEFEESCH. L49 J
hereby
alltioncd repcny fory spot this
purposes. .MECHANICAL
(We) agree ve, indemnify and keep harmless the City of MISC.- REFER TO ORD.
uperlino a liabilities,judgments, costs and experLtes which PERMIT ISSUANCE 10,00 Iq ,_ CONST.TAX 2 //�
ay in ay acerae amt id City in co oviii of he
ranlm this Pciln - MECIL CONT. LIC.N0. MECH.
TOTAL O5 TOTAL -7rIa Z
tgnatum of Applicata on me or '])are
OFFICE COPY