17809 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTI FICATION PERMIT NUMBER BUILDING ADDRESSAPPLICATION & PERMIT I 1 7809
ADDRESS
�o-7 a BUILDING — ELECTRICAL—PLUMBING,-MECHANICAL
UWNEH'a LAI11� IpY PLAN CHECK VALIDATION
NAME.
VJ''s1' K OTY. ELECTRIC PERMIT FEE
• Q20FEJYM�,r--5 PHORE�33-9043
CONTRACTORS y„y �/') UTLETS-SWITCHES-RECEP 10.00/1.00
NA E
Q ' LIC.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS /W"n m� PPLIANCES-RESIDENTIAL 4.00
AD E5
E U t PRONE PANELS 10.00
DATE OF APPLICATION --�
ORRC TELT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
UC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. - SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLEANS. ' 20.00
ADDRESSTs
AMOTORS SEE FEE SCH. J'_ v\��1•
ADDRESS
SERVICE CHANGE 20.00
LICIiNSIiU CONTRACT ORS DECLARATION 67
a u �i I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE(commencing with Section 7000)of Division 3 of the Business and -
a n BLDG. ELECT. PLC. MECH.
H ` z Profusions Cale,and my license n in full force and effect.
o n - License Class Lia Number
g �Opu
Z. Di
H ° ¢ Com radar - Y'f(•)Y
a a BUILDING PERMIT
n a OWNER-BUILDER UP.CLARA'TION - MISC.— O f} ORD INFORMATION
wm I hereby affirm that I are exempt from the Contractor's License - �}.
u O j Law for the following reason.(Sec 7031.5.Businessand Prof vions VALUATION CD 5/FT.
L - Code:An cit or count PERMIT ISSUANCE -70:00
y. y reason.
rtyuirLsapernnit to ronrtmcL altcq Q
2 ¢ a �0 improve,demolish,or repair any structure,prior to its isuan¢.also ELEC.CONTR. - LIC.NO. EIEC,
D 2 requires the applicant for such Permil to file a signal statement that TOTAL 1 PERMIT TO
w he is Pursuant m the pnnivi Section
of the )ofDivision
ivisContractor's 3 cense
of the
H z'Q Law(ChapterndProfessions
or Section is exempt
U theron3 of the
Business and he alleged
Code)or that he is exempt rhtrcfrom and DTV. PLUMBING PERMIT FEE
SE the basAny
applicant
per the alleged exemption.is the
plica t1.action orally03 1.5 STORIES TYPE CONSTR.
u by any aorh ON flit a hu.itndred
dollars
nhe appbealll t0acivil fNeally
of not more than rive hundred dollars(5500).1: ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 1,as owner at the property,or Iny employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their suit compensation,will do the work,and the stn¢ture is nut OCC. ROUP RES.UNITS
intended or offered for sale(See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 y�7�
Cale:The Contractor's License law does not apply to an owner of I'-
• properly who builds or improves thcoon,and who docs such work FIXTURES-PER TRAP 5,00 SG FT,FLOOR AREA T@T.e�[e[AGE
himself or through his own employees,provided that such improve-
areas are not intended or offered fur sale.If,howeveq 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
builder will have the burden of Proving that he did not build or ins- BUILDING USE
prove for purpose of Sale,). I INDUSTRIAL WASTE INTER. R B Other
❑ 1,as owRe,.f the property,nm exclusively contracting with ❑
licensed Lssion,od to The
project a La 1144,Business LAWN SPRINKLERS- 1 INC 5 V.B. _ ps "o^=L NO.
anJ Professions Calc:The Contractor's License Law does not apply U R
to an owner of property who builds or improves thereon,and who - LAWN SPRINKLERS-OVER 5 (EA.) 1
contracts for such projects with a contractors)licensed punuunt to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TACT No PARLE NO.
❑ lamexemptunder Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.
leaven
Owner ])are WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORK HRS'C'OMRENSA'I]ON UECLARA'I'[ON WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certilicatt of cnnsent to self-insure, 39
or a certificate of Workers'Compensation Insurance,or a certified 1 ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.l.
Policy No. Company '
0 ❑ Ceno, it copy' here by furnished FIRE SPR INK ENERGY T-N
Z Z ❑ CertLed .I s flcQ with the 'ity'ia,velion division. MISC,- REFER TO ORD-
0 PIT ea /,(//,�y///jyJ� Y❑ N❑ Y ❑ N❑
CC r� Ch A I: :XIl1FTlb�<�'1nY,1% RKERs. PERMIT ISSUANCE - 4 .. 1`t FLOOD ZONE A.L.u.c.
LU > COMPENSATION INSURANCE PLG.CONTR, LIC.NO. PLG. (�
Z (This section need not be contileted if the Permit is for one TOTAL l Y❑ N❑ V ❑ s N❑
hundred dollars I S 100)or less.)
U O I certify that in the performance of the work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,1 shall not employ any person in any manner so as to
O U become subject to the Workers'Compensation Laws of California.
a Date nPPllnm ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOI ICE TO APPLICANT: If,after making this Cerrificao,of Ex-
♦— ? sorption,you shnuld become subject to the Workefi ComPcnemi.n APPLIANCE 5.00 PLAN CHECK
Provisions of the Wbor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IOOOQF
QM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
tire f e pc,1..encc othe work I...which this permit is sued(See. MICROFILM r
3017,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.DO
me HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address
Lender's NaELECTRIC 4q 01-'
I certify that I have read this application and start that the above VENTILATION FAN (SINGLE) 4.00 Vi
information R ...reel. I agree to comply'wish id city and county PLUMBING 4-01
..dioml«s and relate laws relining to building ns"Retina and BOILER-ODNP(3 H.P.Or 100,000 B.T.U.) 6.00
hirchy caliam d representatives of this city es color ulxm Ibc BOILER-COMP(Oxer 100,000 BTU)SEE FEE SCH. MECHANICAL
ahovom cat o di preprese for inspection purposes
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. 37
upcnlno a ift Oabditics,judgments, costs and expenses whichnseq eCONST.TAX
nay in eny y accrue .gains mid City in cuncs,of the PERMIT ISSUANCE -}0: Q00 � �O4• /
ranting o s pantie 1 MECH.CONT. LIC.N0. MELH.
�j TOTAL ��D� TOTAL -7
o team ontractor Da
OFFICE COPY