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17826 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU LDI NG PROJECT I DENTI FI CATION PERMIT NUMBER ADIRESS Y 2j oper APPLICATION & PERMIT 17SZ� 4U LIDIN P�-LXCCD A -�}� BUILDING -ELECTRICAL-PLUMBING-MECHANICAL OwNER91 /ts nMA,,, _ PLAN CHECK VALIDATION NAME I-•/"V I-W�:� CITY. ELECTRIC PERMIT FEE vHDnE RABO -SWITCHES 10.00/1.00NA LIC,NO. LIGHTING FIXTURES 10.00/1.00 CONTRACTOR IIPPLIANCES-RESIDENTIAL 4.00 CONT FNOnE PANELS 10.00 DATE OF APPLICATION Oq HIT T PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE PC.NO, ENGINEER LIC.NO. SIGNS TRANS. 3.00 ARCH.OR ENG SPECIALCIRC.UIT 5.00 PERMIT VALIDATION ZIP EMP.METER OR POLE INS. 20.00 _I 'y/ Q AORCESS MOTORS SEE FEE SCH. ` 4- ADpR ( D SERVICE CHANGE PAID 20.00 I O¢ ir F 00 LICENSED CONI'RACIURS DI:CLARATION 3 N 1,�TJ�y.rU _ a i n I hereby affirm that I am licensed under provisions of Chapter 9 A IJ ISSUANCE DATE (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT, PLG. MECH. H i Profession,Code,and nrydicen.is in fall force and effect License Class Lic.Number City Of UIIBrtIRQ H F Dam ' Contractor ,l a m s J ,BUILDING PERMIT ¢ ¢ w OWNER-BUILDER DLCLA RATION INFORMATION wA w I hereby affnt that 1 an,exempt from the Cont ores c IS .- REFER TO ORD u O Q Law for the following reason.(Sec.7031.$,Businessa I'r ns VALUATION $/FT. H _ MIT ISSUANCE 10.00 12 Code:Any mol or county repanwhich reqstructuesere. perminots teq ¢¢ improve,demolish,or repair any structure,pri.4lu its i. ,also EL ONTR. - LIC.NO. ELEC. Q o u requires the applicant for such Permit ile a signed so t that TOTAL PERMIT TO w he is licensed pursuant In the Pmvisio -the Contin s icon H s i Law(Chapter 9(cwnmencing with Scet n]000)ofDl n 2 3 o0 4 Business and Professions Code)or that .. s eve. t from n PLUMBING PERMIT FEE slf'-1 vj L_ M i O ¢ H $ the basis for the alleged exemption.Any talion s on 70 STORIES TYPE CONSTR. d ; by any applicant for hundred dollars the .)I �'ivil pct L -DRAIN&VENT-WATER (EA.) 5.00 of not more than five hundred rry.o fm .1: ❑ I,as owner at the prowill do I or or i I to -s na,wits FLOW PROTECT. DEVICE 4.00 their sole compensation,will Jo the wort[h sly'or n t DCC GROUP RES.LINOS intended or offered for sal ISec. 7044, B -u .and f m D AINS-FLOOR,ROOF,AREA,COND. 5.00 Code:The Contractor's I.icenw Law Roes not IPly m un I of property who builds or improves thereon,a ho does s h rk IFI TURES-PER TRAP 5.00SD.FT.FLOOR AREA TOTALACREACE himself through his own employ Id that h.i r 'o meals arere not intended or offelxd for sa c. f'mwever,q tll, buiWi G 5-EA.SVSTEM-11NC.40UTLET$ 6.00 'A or improvement ie sold within one year of complebo e c GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 1 CJ builder will have the burden of proving that he did o uil o nm BUILDING USE prove for PnrPT.of shlc.l. INDUSTRIAL WASTE INTER. 30.00 RES ND CON PB Diner ❑ 1,as owner of the property,am exclusively c racti th �❑ ❑ ❑ ❑ licensed contractors m rons(ruct the pmjcct ISec. 4,Rusin s LAWN SPRINKLERS-1 INC 5 V.B. 6.00 .• ASSESSORS PARCEL NO. and Professions Code:The Contractor i License Law saes not app to an owner of property who builds or improves IT rc and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 contracts for such projects will,a co.racmrts)Per it pursuant to the Cnntmctor's License Lhw. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO. ❑ I am exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT .6.00 re"On Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. WORKERS'COMPENSA'IION DECLARATION WATER TREATING EQUIP. 5.00 1 hereby affirm that I have a certificate of consem to selfi.sure, Z' or a certificate of Workers'Compensation Insurance,or a cerlifed 3 ZONING ENG.SITE NO. copy thereof(Sec.3800 La,C.). Policy No. C pang C) ❑ Ceniticdco", m reby furnished. - FIRE SPRINK ENERGY T-24, Z Z ❑ Certified co is tiled •wit h a c' infection division. MISC.- REFER TO ORD. F O APPIis t Y ❑ N❑ Y ❑ N❑ Q N � A' E OI'EXIT. N B M M'URKIiRS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C. LU > COMPENSA110N'INSURANCE PLG.CONTR. LIC.NO. PLG. CL O (This section meed not be completed if the permit n for One - TOTAL 4 Y❑ N❑ Y ❑ N❑ Z hundred dollars IS 100)m less.) U O 1 certify that in the performance of the work fur which this Iwr- CITYMECHANICAL PERMIT FEE FEE SUMMARY LL 1- mit is issued.I shall not employ any person in any manner so as to U becomesubject to the Workeri Compensation Laws of California. a Dan' Applicant ALTER OR ADD TO MECH. 5.00 BUILDING } N NOTICE TO APPLICANT: If,after making this Certificate of Ex- F-. ? eminmr, on should become subject to the Worker..'Colnpensalion APPLIANCE 5.00 PLAN CHECK prisions of the Labor Code, yon must I..th eith cmnply with CJ sucovh provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10)MOC.F.ML) 4.00 FEES CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00C-F.M) 6.00 SEISMIC FEE ' I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 the perfommnce of Il,ie work for which this permit is issued(Sec. - MICROFILM 3197.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 L cruder',Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 49V� Lender's Address ELECTRIC I cerlify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 PLUMBING information is correct, I agree to comply with all city and County ordinances and stale laws relating to building construction, and 801LER-CC M(3H.P.or100,000B.T.U.) 6.00 d"'1 I' hereby authorise roperty forms of the City m enter upon the BOILER-COMP (Oser 100,000 BTU)SEE FEE SCH. MECHANICAL hereby authored Property for inspection of purposes. (We) agreve, indemnify and keep harmless the City of MISC.- REFER TO ORD. 7 _ ^ ufyncA liuhilities, udntscostsPERMIT ISSUANCE 10.00 I� _ CONST.TAXyoy accru again said City in conay ntt f theGis Per r MECH.CONT, LIC,N0, MECH. TOTAL ngO� TOTAL / a arc of ppllunt/ Ontrector Uat `I ��j'j L OFFICE COPY