17808 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTI PERMIT NUMBER
(CATION
uuowc APPLICATION & PERMIT > 17808
a
ooREss BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
LOCo71 G
OVaNER'SlDri(A tp PLAN CHECK VALIDATION
NAME IL�I� 11'"�I`—
��F'.J 77J31�4� OTYELECTRIC PERMIT FEE
PRorvE
CONTRA ORS
NAME eL,.QYLYLY� 'G> D�Y1/fJU UTLETS-SWITCHES-RECEP 10.00/1.00
�.���,/�s d �LIC.�No.,/ LIGHTING FIXTURES 10.00/1.00
P,OrvrHAc oRPR7/r//�m��wT'1pp LIANCES-RESIDENTIAL 4.00
ADDRESS
PRONE , PANELS . 10.00 DATE OF APPLICATION
onCR ECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.0`NO.
ENGINEER
LIC.NO SIGNS TRANS. 3.00 '
ARCH.rt ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
�DDRZIP TEMP.METER OR POLE INS. 20.00 _ Q
APPLICANT'S MOTORS SEE FEE SCH. `
ADDRESS .,
SERVICE CHANGE 20.00 `
o ¢ i q
Foo LICENSED CONTRACTORS DECLARATION
G u p 1 hereby attire,that I am licensed under provisions of Ch.ptcr 9 _ ISSUANCE DATE
w (com reacing with Section 7000)of Division 3 of the Business and
(/i ¢ v6i BLDG. ELECT. PLG. M .
F o z Professions Code,and my license is in full force and effect. a�A t's .�
0 o"./ - License Class Lit:Number JAY
o y- Date Contractor - Y"
F
a m - a BUILDING PERMIT
a OWNER-BUILDER DECLARATION
R O a" MI C.— City, RD INFORMATION
w g w u I hereby affirm that I am exempt from the Contractor' License 1a7.__ vgLUATION S/FT.
F .. o a Law for the following reason.(Sec.7031.5,Businessend Professions p MIT ISSUANCE -00.90 I --
Cade:Any city or county'which re luiresa permit to construel.alt
P m¢ M improve,demolish,or repair any st,.ctLrc.prior to its iss a ELE NTR. LIC.NO. 1 /}��/�
ar o a"`i' ELEC. (O 12 7 `-G
sc wR u requires the applicant for such permit to file a signed statement Lha TOTAL'5� PERMIT TO
$ he u licensed pursuant to the provisions of the Cantr Dr's License
F a i Law(Chvpter9(commenein8 with Sect ion 7000)nf vi'on Sof the
a Business and Professions Code)or that he is exempt a from and PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of S 4 n 7031.5 STORIES TYPE CONSTR.
a by any applicant for a permit subjects the applicant to a it penal -
of not more than five hundred dollars(S500)J: q ER-DRAIN&'VENT-WATER (EA.):5.00 —�
❑ 1,as owner of the propurty,or my umpinyees wit wages I IINDUS
FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sale compensation,will do the work,and the stru ju s n t
intended or offered for sate (Sec. 7044, Business and Pio 'o A S-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an ow e o 1�
property who builds or improves thereon,and who das such r TU ES-P R 5.00
• himself or through his own employ.,provided IheI ch nu eve- T Sa FT.FLOOR AREA T 6F
mems are not intended or offered for sale.If,however,the Ing S- A.SYS I C.40UTLETS 6.00 / ,�7 4f
or improvement is sold within one year of completion, S- A.SV - R 4 (EA.) 2.00 I
builder will have the burden of proving that he JIJ not build or ie,- BUILDING USE
for RES IND CON PB Other
prove 1,as owner of sale.p RA TE INTER. 30.00
❑ L a of the property,he exclusively contracting with
licensed contractors to cimxuo�ctContra the project(Sec, 71}44,ofapply Business WN IN E S- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Cate:The Contractor's License Law does not apply ,
to an owner of property who builds tr improves thereon,and who S LE -OVER 5(EA.) 1.00
contracts for such cense L with a cnntraaturlsl licensed pursuant W (TAR Y-STORMEA.200t1/10.001hC Contractor's License Law: TRACT rv0. PARCEL NO.
❑ tum exempt under sot. B.&P.a for 011reason ATER EATERW/VENT '. 6.00
Owner Date WATERS STEM 5.00 ACC.DATE ACG FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certifiame of consem to self-insure. —'Z— ZONING ENG.SITE NO.
or a certificate of Workeri Compensation Imurznce,or a cenificd .
copy thereof(Sec.3800,Lah.CJ.
Policy No. Company
O ❑ Certified copy'( ercby furnished. FIRE SPRINK ENERGY T 24
❑ Certified co G filed•with t, inspection division.
ZO Applica MISC.- REFER TO ORD. Y � N� Y [ N�
~ rn c�� PERMIT ISSUANCE iB:00 ��
� CG 'I A GOF IiXEMI"I' NOM ORKERS' FLOOD ZONE A.L.II.L.;
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. �I /; ❑ ❑ ❑ ❑
CL O (1)us section need not he completed if the penin is for one TOTAL Y N Y N
::) Z umdecd d.Pm,(E 100)nr levs.)
U O 1 cc,tily that i" the performanec of Due work fur which this per- Q.nr MECHANICAL PERMIT .FEE FEE SUMMARY _
LL H mit is no,d,1 shell not cmpluy any rensrm m any manna w as In
Ow become subject to the Workers'COlnpenvution Laws of California.
Ci. Dat° npplmam ALTER OR ADD TO MECH. 5.00 BUILDING 7 a p
} m NO'FICB TO APPLICANT: IL after making(his Certificate of F.-
(_ ? sorption,you should bcaomc smbjcml to the Workers'Compcnvlion APPLIANCE 5.00 PLAN CHECK
provisions of the labor Cate, you must forthwith comply with FEE I
U such provisions or this Permit shall he deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M,) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER 10=C.6NL) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Ste. MICROFILM
3097,Civ,C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lende is Name HEATING UNIT(OVER 100,000 B.T.U.19.50 51 �_
Lender's Address ELECTRIC
I certify that l havereadthis application and spm that t he above VENTILATION FAN (SINGLE) 4.00
Inforlances n correct. 1 agree li emnply with all city and county �LER ��p(3 H.P.or 100,000B.T.U.) 6.00 PLUMBING 51
uNinuneas and state lows relining ui building construction, and
hereby auolorize representatives of this city to enter upon the .BOILER-COMP _Oxer 100,000 BTU)SEE FEE SCR. MECHANICAL 5
above mentioned property for inspection put,,,, - I
(We) agree to save, indemnify and keep hxnntess the City of MISC.- REFER TO ORD. 3q
uperti en ag sI liabilities,judgments,casts and expenses which PERMIT ISSUANCE 10-00 —ITT1= CONST.TAX ��
ey in an ay acme against said City in consequ nice of the
ranting is penniL MECH.CONT. LIC.NO. MECH.
Q/) TOTAL 5' �$ TOTAL
a u of ppbCan Contramor Date
OFFICE COPY