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