17810 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFI !TION PERMIT NUMBER .
But 4DING
ADDRESS , - Ip-r- 5 APPLICATION & PERMIT r�81 O
ADDRESS
BUILDING — ELECTRICAL—PLUMBING —MECHANICAL1. I
bLNNER9 ' A"JQyIA IO Ii PLAN CHECK VALIDATION
NAMEs.yyy 1�1^I !'— TY. ELECTRIC PERMIT - FEE
. -�Tles ONE�33Q�+
NONERAc O"S�d -7 UTLETS-SWITCHES-RECEP 10.00/1.00
✓✓�Y��� n'L LIC.No.�fte LIGHTING FIXTURES 10.00/1.00
CONTRACTOR S �S PPLIANCES-RESIDENTIAL 4.00
Aoo ESs (J' Y -
1 PHONE PANELS 10.00 DATE OF APPLICATION
AREHIFfYCT PLAN CHECK FEE V,C,NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
uC.NO. SIGNS TRANS. 3.00
ARCH.ss ENO, SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 1 p_Ly O
APPuc4Nrs MOTORS SEE FEE SCH. "l
Aoo REss f1
SERVICE CHANGE •'" 20.00 ZiT '�'`���
0 0 o LICENSED CONTRACTORS DECLARATION •"`r x�r _L
ar u U I hereby affirm that l am licensed under provisions of Chapler9 — - ISSUANCE DATE
Na (con nnocin with Section 7000)of Division 3 of the Business and
¢ R BLDG. ELECT. PLG. MECH.
H N i 1'rofe.aions Code,and my license is in full force and effect.
z o et — License Claus Lic.Number
O F O Date Contractor
el y f BUILDING PERMIT
¢ 0 a U
OWNER-B UILUIiR DECLARATION INFORMATION
K
; LL I- 1 hereby affirm that I am exempt from the Contractor's Licermse MISC.- EF RTO ORD VALUATION S/FT.
F LL o j Law for the following reason.(Sec.703 L5,Business and Professions PERMIT ISSUANCE }@00 I 'GO
3 � v, Cale:Any city orcounly which requires a permit to construct,alter,
QQ y nh
2Q O improve,demolish.or repair any structure,prior to its issuanre,also ELEC.CONT". LIC.NO. ELEC.
ra
O u requires the applies nt for such permit to File a signed statement that TOTAL
Ew w he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
HiQ
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthc k'A� 11 -
Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE S�W L✓
¢ 0 the basis for the alleged exempt inn.Any violation Of Seat ion 703 L5 STORIES TYPE CONSTR.
e- by any applicant Cora permit subjeasthe applicant moa civil penalty ALTER-DRAIN&VENT-WATER IEA.) 5.00
of not mom than Five hundred dollars fS500)f: V-P
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
ntended or offered for sale (See. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 ' y� q
Code:'fhe Contractor's License Law dons not apply to an owner of K 5
_
property who builds or improves themon,and who does such work FIXTURES-PER TRAP 5.00 So.rFT.FLOOR AREA„rgr/gk eACREAGE
himselment,f or through his own employees,provided however,
such improve-
mcnts me net hroug intended tonor emplo ee sale,If,ed that such
he mpovbuilding GAS-EA.SYSTEM-1 1N T
A 61M
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM=OV 4 A. ,00
builder will have fire burden of proving that he did not build or,im- - TACC.DATE
BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE I 3IND CON Pe other
O 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
liconwd contractors In construct the project(Sec.7044,Business LAWN SPRINKLERS-I I C 5 V.B. 6. SSESSORS P ARCELNO.
and Profc.oms Coda:'I'ho Conrruclur's Licenv�Ww does not apply
to un owner of property who huilds or improves thereon.and who LAWN SPRINKLE SOV .) 1 '
contracts forsuch projeciswifhaeortractons)licensed pnocant to SEWER-SANITARY-STORM EA.200ft/10.
the Contractor's License Law. Y . PARCEL NO.
❑ 1 am exempt under See.—,B.&P.C.for this WATER HEATER W/VENT 6.00
naVan
Owner Dale WATER SYSTEM 5.00 ACC.FILE N0.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00q
I hereby affirm that I have a certificate of consent to sal Gismos. 3-1
or a certiflaate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy theomf(Sec.3800,I.ah.C.).
Policy No. C parry _
O ❑ CcrtilieJ cop3' Beeby famished. FIRE SPRtNK ENERGY T 24
IZ" ZO ❑ Cert it icd to is Med•with/�c_n�mslKclion division. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
AppliC rat / Y N Y N
� ti CCR I'ICAI'h OFHXEMVYII1OONN FROM WORKERS PERMIT ISSUANCE AG:Go ) FLOOD ZONE A.LU.C.
Wim.Q COi\IPENSATION INSURANCE PLG.CONTR. LIC NQ PEG TOTAL 51 �D Y❑ _ N❑ Y❑ N❑
CL Z (This section need nm he completed if the permit is for one _
hundred dollars(S 100)or less.)
L) O 1 certity that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL - mit is icamd,1 shall nor employ any pec n in any manner so as to
become subject to the Workcd Compensation Laws of California.
0i Uwc Applicant BUILDING OR ADD TO MECH. 5.00 BUILDING
- N NO'1'IC17 'f0 APPLICAN I': IC atter making this Certificate of 1!x-
1154
Z emotion,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions m this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10f)MCF.M.) 4.00
CONSTRUCIION LENDING AGENCY AIR HANDLING UNIT(OVER 10)OODC.F.M.) 6.00 SEISMIC FEE 8 _
I hereby affirm that [leen is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
tire performance of tile work for which this permit is issued(Sec. MICROFILM -
3097rCIv.C.). x'.s HEATING UNIT(TO 100,000 B.T.U.) '8.Do
Lender's Address
HEATING UNIT(OVER 100,000 B.T.U.)9.50 �I C08
Lenders Address - ELECTRIC
I certify that I have read this applicatmn and state that the above VENTILATION FAN (SINGLE) 4.00 SDS
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-CGWPI3 H.P.or100,0008.T.U.) 6.00 5�
hereby authorize representatives of this city to enter upon the BOILER-COMP IOxer 100.000 BTU)SEE FEE SCH. MECHANICAL
above-mentiu51
ned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. QJ
uperano agai liabilities,judgments, costs and expenses which - �Y J CONST.TAX ry•�-
say in any accrue against id City in croscq c « f the 6.9
PERMIT ISSUANCE 10 Ins(
ratio,of pe, MECH.CONT. UC.NO. MECH.
TOTAL / O7
TOTAL V rO
s Lure of Applicant/Contractor Dam 1
51!uC
OFFICE COPY