17827 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
BU I LOING PROJECT IDENTIFICATION'
BUILDING l/• OE If'�jZ (�Ui1t APPLICATION HPERMIT
OGRESS t1LDING -ELECTRICAL-PLUMBING -MECHANICAL F�
17827
20&�Pr, 7RA710& rJ
OWNERS L(Al1 DTV. ELECTRIC PERMIT PLAN CHECK VALIDATION
FEE
PHONE
NRsd
NAME
� �G UTLETS-SWITCHES-RECEP 10.00/1.00
LIC,NO IGHTING FIXTURES 10.00/1.00
ADDRESS Rs q/ PPLIANCES-RESIDENTIAL 4.00
AZ�oPHONE.%-,�/ PANELS 10.00 DATE OF APPLICATION _
AOR " ECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE .c.rvo.
ENGINEER
uc.No. SIGNS TRANS. 3.00
AR. ENG. PERMIT VALIDATION
ADDRESS
ss _ SPECIAL CIRCUIT 5.00 ,
ZIP EMP.METER OR POLE INS. 20.00 �_� `/_9d
ADDRESS ACTORS SEE FEE SCH. (
APPLICA
ICE CHANGE FWD 20.00
Foo LICENSED CONI'RACfI`//��=-
Q 2 u 1 hereby uflinn Thal am licens�/Isii �Q ISSUANCE DATE
H a w (commencing with Section 70001 OI Division 3 0l the usmef R BLDG. ELECT. PLG. MECH.
MAY
" h z Professions Code,and my license is in •and effect 7
z o m - Liccnsc Clan Lia N
rm ,w Dam contractor Cit/ of '"n no
N, m I BUILDING PERMIT
¢ a a OWNER-BUILDER DIiCLA RATION
o> " MISC.- REFER OORD INFORMATION
X 3 LL r 1 hereby affirm that 1 am exempt from the Contractor's Licenses VALUATION VFT.
ta Is O� Law for the following rcasu¢(Svc,703L5,Businessand Professlmn PERMIT ISSUA C 10.00
Code:Any city or county which rnpJresa,Cohn loconstruct,alter, I
R ¢ ¢Q improve,demolish,or repair any structure,prior to its issuanm,afw ELEC.CONTR. L .NO. ELEC. '/.7'
D u requires the applicant for such permit to Ills a signed statement that TO AL 5I PERMIT TO
E
he is licensd pursuant to Ibe provisions of the Contractor's Lie rove
" iQ
Low(Cllapter9(commencing with Section 7000)of Uivisian3ofthe F-yI '1
i LI Business and Professions Code)or that he is cxcm Pt therefrom and Q Y. P UM I E EE
¢s- the bvsu for the Alleged exemption.Any violation of Section 7031.5 STORIES TYPE COrvSTRe
u ; - by any applicant for IT pemtit subjects the applicant Wa civil penally LTER-DRA EN -W E EA. v�Is..l
of not mom than five hundred dollars(S500)J:
❑ 1,as owner of the property,or my employees with wages as PACK FL P TE E 4 0 OCC.GROUP RES.UNITS
sole compensation,will do the work,and the stmcmre is not
intended or offered for sale (Sec. 7044, Business and Prolessto., DRAI F ,R F E CON 5. 0 3
Coda:The C,HRokmi s Licenw Law docs not apply m un owner al'
property who builds or Improves thereon,and who docs such work IX -PER 1 5. 0 SO.FT.FLOOR AREA TOTALACREAGE
• himself or through his own employees,provided that such improve- A ./ 1 C.4 U S 5. 'C.�-7 6r'Qr AM
merits are not intended or offered for sale.If,however,the building :J /
or improvement is sold within one year of completion,the owner- S-E V -O E E 2.00
builder will have the burden of proving that lie did not build or inh- BUILDING USE
prove for purpose of sale.). DUST I ASTE I TE 30.00 RES IND CON PB Owes
❑ I,as u r of the properly,am exclusively contracting with rLJ' ❑ ❑ ❑ ❑
licensed contractors to construct the project see.7044„Business LAWN SP KLERS- 1 INC 5 V B. 6.00 ASSESSORSPARCELNO.
and Professions Code:'I'lie Contractor's License Law docs not apply
to an owner of property who builds or improves Iherann.and who LAWN SPRINKLERS-OVER 5-(EA.) 1.00
eonlracts for such projects with a contraclogsl licensed purvmnt to SEWER-SAN V-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.far this ,WATER HEATER W/VENT 6.00
rea50n
Owner Date WATER SYSTEM 5.00 "' ACG DATE ACC.FILE NO.
WORK 17 RS'COM PENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby alfirm that I have a certificate of consent m wit rv,ure' �� - ZONING ENG.SITE NO.
a cetlific-ate of Workers'C mpenvti.R Insumncc,or a ceitit ieJ
spy thereof IScc.3800, .C.).Polk No. C any -
❑ Cmtiticd copy' Baby fqurn J. FIRE SPRINK ENFRGr,L24 .
Z = ❑ eRificd c is filed At he inspection division. MISC.- REFER TO ORD.
O App nt r ❑ N❑ V ❑ N❑
CC
w I 'ICAT'EOP EX k 10, FROM WORKERS' PERMIT ISSUANCE 10.00 12-- FLOOD ZONE A.L.U.C.
W > COb1PEN'SATION INSURANCE PLG.CONTR. ❑c.NO. PLG. C (0CL 0 Y❑ - N❑ Y❑ N❑
(This .vection need not be completed'if the permit is for one - TOTAL :J
hundred dollars($100)or less.)
U O 1 certily that in the performance of the work for which this per- Qty MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers Compensation Laws of California.
�'ad Dalc Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ H NOTICE TO APPLICANT: If,after making thh Certificate IT - -
? enhption,you should become subject to the WorkersCompensation APPLIANCE 5.00 PLAN CHECK
provi mis of the Labor Code, you must forthwith comply with FEE `
U .rich provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1Op00CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER l0fMC.F.M.) 6.00 SEISMIC FEE ,8
Courcby affirm that there ot a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the pa,formance of the work fur which this permit is nsucd(Sce. MICROFILM -
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 -
Lcndcr'sName HEATI NG UNIT 100,000 B.T.U.)9.50 "JI Cob
Lender's Address ELECTRIC
I certify that I have read this appllcatiun and state that the above VENTILATION FAN (SINGLE) 4.00 CoS
information is correct. I agree to comply whlh all city and county' PLUMBING 15
ordinances and slate laws reaming to-hiilding construction, and BOILER'COMP(3 H.P.or 100,000 B.T.U.) 6.00 5 -'
herby aulhurim mpresentatives of this city to ewer upon the BOILER-COMP IOeer iw,OW BTU)SEE FEE SCH. MECHANICAL 51 f0
above entionedproperty for inspection purposes.
(Wc) egreo
VV-'re, indemnify and keep harmless BIc City of MISC.- REFER TO ORD.
_ upertino a i t tiebilities,judgments, cost, and expenses which CONST.TAX ry
vy in a oy ace aqui said City in tone( rice C the PERMIT ISSUANCE 10.00 Ia ,-,� /�. /
anon Lhis Re MECR.CONT. LIC.NO. MECH.
�/ TOT"51 66 TOTAL / /0•G�
alurc of pliant Contractor Ua e 5
OFFICE COPY