17834 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION - •
,PERMIT NUMBER
BUILDING 9 APPLICATION & PERMIT
17834
•oon�-C�[��Q
UI LDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S vI V - PLAN CHECK VALIDATION
NAME OTV,. ELECTRIC PERMIT FEE
• FVQK-TI E3 RGNET5 9Lo�
NAME
CONTRACT. f�� / �b�IJ�V UTLETS-SWITCHES-RECEP 10.0011.00
LIC.No. s3 LIGHTING FIXTURES 10.00/1.00
ADDRESS TORPC7 /J/� W APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
OR .cT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.Q=O.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCHR.OENG
. ='RMIT VALIDATION
ADOREsSPECIAL CIRCUIT 5.00
ZIP EMP.METER OR POLE INS. 20.00 ( �D
APPLICANT'S -
ADDRESS MOTORS SEE FEE SCH. -
- r{ ///•
SERVICE CHANGE 20.00 n J F►'o LlG LI ,
o o LICENSED CONTRACTORS DECL\RA'f10N � 3 1 - 1, 'V^�//
u 0 1 hereby affirm that 1 am licensed under provisions of Chapter 9 `� �Z ISSUANCE DATE
y a (commencing with Section 7000)of Division 3 of the Business aad t BLDG. ELECT. PLG. MECH.
H 4 z Professions Code,and my license is in full force and effect w A 1 Ne
i o 2 - License Class Lic.Number
9 a H w Datc Contmaor \�\ `Lt"�
g k3
Z-
¢ 'c ¢ a OWNER-BUILDER DECLARATION of Cnnarfin(► BUILDING PERMIT
Aa=" MISC.- �� �• REFERTOORD INFORMATION
ea ;LL F 1 hcrcb`y million Ihul 1 am exempt Irma the Contractor's s License VALUATION S/FT.
F LL o a Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 12 _
Code:Any city or county which requiresa Perot toconstuta,alter, �7 /-�
R2 4 improve,demolish,or repair any structure,prior to its Issuune,,also ELEC.CONTR. LIC.N0. ELEC. �� CD I L� VOO
po u requires the applicant for such permit to file a signed statement that TOTAL
a Wply he is licensed pursuant to Lire provilsions of the Contractor's License PERMIT TO
H
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a
Business and Professions Code)or than heisexemY.
pt therefrom and OTPLUMBING PERMIT FEE S L'
¢ = $ the basis for the alleged exemplim,Any violation of Section 703 LS1 STORIES TYPE CONSTR.
s ; by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 5.00 V-N
of not mor,than five hundred dollars 1$5001.1'.
❑ 1,as owner of the prperty,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure n not
intended or olfered for sal, (Sec. 7044,Business and I'rofenions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 K_7,- ,
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO:FT.FLOOR AREA TOTALACREAGE
e himself or through his own employees,provided that such improve- /�
V--
Fields are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 1 NC.4 OUTLETS 6.00 I GQ� `i16 nv�
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 ' ✓CCJJ BUILDING USE 4CD
builder will have the burden of proving that he did not build,or im-
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON ,PB other
Cl I,irs owner-of t11c property,am exclusively contracting with ❑ ❑ ❑ ❑ Q.
licensed contractors to construct the projeci 1Sac. 7044,Business LAWN SPRINKLERS-1'INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts forsuch projectswith a contranorls)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
TRACT NO. PARCEL NO.
the Contractors License Law.
❑ I am exempt under Sec. .N.&P.C.for this WATER HEATER W 6.
reason
Owner Date WATER SYSTEM
C.DATE ACC,FILE N0.
' WORAISRS'COMI'IiNSAT10N DECLARATION WATER TREATING O I
I hereby affirm that [ have a mrtifcate ofconsent to self-inNoe.
or a certificate of Workers'Compensation Insurance,or a certified ZONIN ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.). DATE. ;
Pmiey Nss CO CReny 9 .
O ❑ Cerlilied copy •by Hruisl1ed. FIRE SPRINK
A IIn ENERGY T 24
Z ZO ❑ C Wiled co o bled wit )te ci inspection division. MISC.- REFER TO ORD. _ Y E] N❑ Y'❑ NE]c �
CC run ✓1 1 F PERMIT ISSUANCE 10.00 FLooO zorvE A.L.U.C.
'� CliICATIiO YIiA N PROs WORK :RS' 1zJ. -
LU Q COMPENSATION'INSIIRANCI. PLG.CONTR. LIC.NO, TOTAL 51�� Y E] N❑ V❑ N❑
1'I his section need not be completed if the permit is for one
Z) Z hundmdd"Ilars(Sl00)"A11.)
U 0 1 certify that in the performance of time work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,1 shall not employ any person in any manner w as m
O w become subject to the Worker Compensation Laws Of California.
y
Date-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} run NOTICE TO APPLICANT; IL aNcr making this C,nifieme of Fs-
� Z ,mption,you should becom,subject to the Workers'Compensation APPLIANCE 5.00 PLAN.CHECK
provisions of the Labor Code, you must forthwith comply with FEE. '
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10SWC.F.M.)'. 4,00
CONSI'RUCTION'LENDIN(i AGENCY AIR HANDLING UNrNOVER 10MC.F.M.) 6.00 - SEISMIC FEE _
1 hereby affirm that then is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which the permit N issued(Sec. MICROFILM �-
3097,Civ.G). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Address
Lender's Address - HEATING UN IT IOVER 100,000 B.T.U.)9.50 ELECTRIC 51
1 certify that 1 have read ffinapplication and state that the above VENT I
ENTI LATI ON FAN (SINGLE) 4,00
• • information is emrreel. I agree m comply with all city and eFunty PLUMBING
Ordinances and state Inws relating to building construction, and BOILER-DOW(3 H.P.Or 100,000 B.T.U.) 6.00 -�
hereby authorize mpra�wyntatives of this city to enter upon the BOILER-COMP (Over 110,000 BTU).SEE FEE SCH. MECHANICAL
t
ve-mentioned pro / for inspection purposes. q 51
We) agree to vie,/indemnify and keep harmless the City of MISC.- REFER TO ORD. J ertino ugai t I` !litres,judgments, costs and expenws which PERMIT ISSUANCE. 70.00 CONST.TAX /y'l in any accrue inst 'd City in conseyuanc of the 1•Z - 3 a.• /,�"
Ii go sp,rtnIL L MECH.CONT. LIG NO. MECH. -
3 TOTAL 51�$ TOTAL (o
are of,
t/Contractor 15.1e '
/ 9
OFFICE COPY