17807 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING 0 (-,e APPLICATION & PERMIT i. O 0
ADDRESS g o
r7 5s, Ga t-ckyk L BUILDING -ELECTRICA L-PLUMBING-MECHANICAL
OwNER'BPLAN CHECK VALIDATION
NAME L[a � NI nICZ{� �/'y�j / OTV. ELECTRIC PERMIT . FEE
i -1(las PHONE / ✓.l�lY
NAMECONTRACTORs g* UTLETS-SWITCHES-RECEP 10.00/1.00
NAME .CL L(yE/ / f`yt J?(/
T
LIGHTING FIXTURES 10.00/1.00 -(
.ONTR CTOR's
AooR ss a�QQCI �.$• PPLIANCES-RESIDENTIAL 4.00 -
PHONE � ' PANELS 10.00 DATE OF APPLICATION
OR
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
sec.No. '' SIGNS TRANS. 3.00ARCH OR
ADDRESS cove. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 1
APPuc ANT'S MOTORS. SEE FEE SCH.
AODREss
SERVICE CHANGE TpAaJP 20.00 ry��. I�.� �y.y�
C, a 7 39 (D N.1l..T.'/p4j`pP�'�`�
F o o LICENSIiD CONTRACTORS DECLARATINAd ..n,t
a v I hereby affirm That I am licensed under provisionW
Y 1 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of th 8 v t
y a 'BLDG. ELECT. PLG., MECH.
r-y z Professions Code,and my liana is in full force and a❑elf. V IK n
O i m o Liana Clan Lic.Number 1^P
H ve F j Date Contractor, f BUILDING PERMIT
SC a OWNER-BUILDER DECLARATIONo a D INFORMATION
ww 1 hereby affirm that 1 am exempt from the Contractor's LicenseREFER TO ORD
F LL 0 a Law for the following reason.(Sec.7031.5,Businlssand Professions PERMIT ISSUANCE .40:00 /L
O VALUATION $/FT.
Code:Any city orcounty which requires a Permit to construct,alter, c 4
se ra ¢ o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEG LOS -�
wO u requires the applicant for such permit to file a signed statement that TOTAL 51 / PERMIT TO
$ he is(Chapter
9(commencing
co cat to the provisions of the )of Division
License a.-.. D t -
H x i Low less and
9lemnm s Codewith Soclthat l e is exempt
t the of o and 1F IW/IV/
the
a Business and he alleged
erupt or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
aIm- $ the basis for the alleged exemption.Any violation m`Snfiom703I.5
malty STORIES TYPE CONS-JR.
i ; by any applicant fora hundred
tdollars the applicant Ioacivilpenally - �_ �/
of nut more than five hundred dollars($500f): ALTER-DRAIN&VENT-WATER IEA-15.00 (Y
❑ I,as owner of the progeny,of my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their.sole colllpeasnliun,will do the work,and the structure is not OAC.GROUP RES NITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 �3
Code:'fire Contractor's License Law does not apply to an owner of
property who builds or improves thereon.and who docs such work FIXTURES-PER TRAP 5.00 sac FT.FLOOR AREA �To7AL ACREAGE
meats are not
hhisde own employees.for sale.
11.ed however,the
improve- GAS-EA.SYSTEM-1 6.00 /6Y7 (Tf]I (60
mems are not improvement is s ld orthin on for sale.If, Oto budding �/'
or derwillvis sob within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
rmve for purpose of sale.). INDUSTRIAL WASTE INTER. 30,00 IND eoN Pe Omar
❑ I,as owner of the property,am exclusively contmE eting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(See. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Conlmator's 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 for such projects with a Omiractorlsl licensed pursuant to
the Coothmt.,s Lice eLaw. SEWER-SANITARY-STORM EA.2001t/10.00 TRACT NO. PARCEL NO.
❑ lawn exempt under Sec.-.B&P.C.for this WATER HEATER W/VENT 6.00
reason
Owncr .Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
W'ORKERS'COMPFNSATION DECLARATION WATER TREATING EQUIP. 5'.00 p z
1 hereby allimt that 1 have a certificate of consent to sell-insure, 3 1, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy tlo,cof(Scc.3800,Lab.CJ.
Policy No. Company
O ❑ Certified copy hereby furni A FIRESPRINK ENERGY T-24
Z Z ❑ C Rdiod is tiled with the c' y inspection Jivisimt. MISC.- REFER TO ORD.
O APPlica n Y❑ N❑ y ❑ N❑
~ rn PERMIT ISSUANCE 4-0:00
CC CER 19 C'A'I'Ii UP IiXIi PITON PROM WORKERS' I 1 FLOOD ZONE A.L.u.C.
W COMPENSATION INSURANCE PLG.CONTR. 'LIC.NO. PLG. (n
CL 0' This scclidn need nut he completed if the perY mit is for one TOTAL 5I ❑ N❑ v ❑ N❑
Z) Z hundred dollars IS 100)m less.)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
D_ U mit is issued,I shall not anploy any pc,,,,in any Ininner m us to
become subject to the Woikeri Compeltution Lawsof California. 73
W Dam Applicnt ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPIACAN'1'; If,after making this Certificate of Ex-
Z emption,you should become subject to the WorkersCompemartmo 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 10=17-F.M.) 4.00
CONSTRUCTION I.I NDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE r�
I hereby affirm that then is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the Performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's AS H EATI NG UNIT(O V ER 100,000 B.T.U.)9.50 Ir�
Lender's Address ELECTRIC i
I certify that I base rend this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and coumy ggLER-COMP13 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
above mentioned proyes
ordinances and talc laws odaling lex building cmtsfudimi, and
hereby authorize mpnsentatna of this city to enter upon the BOF
R-COMP IOser,100,000 BTU)SEE FEE SCH. MECHANICAL
pIL
property for inspection purposes.
(We) agree to saw, indemnify and keep harmless the City of MISC.- REFER TO ORD. y'
uperttno agai st Brilad.les,judgments, costs and expenses which . PERMIT ISSUANCE 40-00 CONST.TAX a10_,0
ay in any vy accrue against sand City in consequence of lire vrmiL , MECH.CONT. LIC.NO. MECH.
iia T`TA G$ TOTAL /
ore of Applicant/Contractor Date - /
OFFICE COPY
,i