17806 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
eU1LDING PROJECT IDENTIFICATION APPLICATION & PERMIT
Bmtmuc 17806,
ADDRESS - -
rzQjo-i9 �r C. C BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S ' / VJ'TY - PLAN CHECK VALIDATION
NAM, 1``1`` f��) 'I r'- 1 GTY. ELECTRIC PERMIT FEE'
WND 1��� PRONE
CONTRACTOR'S
NAMEUTLETS-SWITCHES-RECEP 10.00/1.007D-
Lc.NO. LIGHTING FIXTURES 10.00/1.00
LON RACT ,f ` .� PPLIANCES-RESIDENTIAL 4.00
A DDR Eg
Ss 61'i(' ! /, J
PHONE l PANELS 10.00 DATE OF APPLICATION
ARC ECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00 --
ENGINEER
LIC.No. SIGNS TRANS. 3.00 '
ARCFE SS ENG. , SPECIALCIRCUIT 5.00 PERMIT VA LIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT MOTORS SEE FEE SCH.
ADORES$
SERVICE CHANGE 20.00
,
Foo LICENSED CON'I'RAC TORS DECLARATION v
¢ U o I hereby affirm tiwt I am licensed under provisions of Chapter 9 - _ ISSUANCE DATE
y2w (commencing wild Section 7000)of Division 3 of the Business and
a wBLDG. ELECT. PLG._. MECH.
F 6 z Professions Coda and my license is in full force and effect.
Z o 6, - License Claw Lin.Number MAY ,14
9 Y F w Dale Contractor OOopr/1�
¢ '¢ a OWNER-BUILDER DECLARATION
IOJy -BUILDING PERMIT
a o 6 u I INFORMATION
w ; E I hereby affirm that I am exetilpt from the Contractor's License - REFER TO ORD
cc o a Law for the following reason(Sec.7031.5,Business and Professions PE ANC 0.00 1EE
U -ION S/FT.
� - Code'.Any city or county which tenures a Pemait to construct,alter, / I4 ODQ
¢ ¢ ¢ Q improve,demolish,or repair any structmL,onor1D❑s issuance,also TR- LIC.NO. ELEC. /
tt requires the applicant for such permit LO file a signed statement that OTA
L YREfLMIT TO P.
Z
Pe he is licensed pursuant to the provisions of the Contractor's License W
Far
Law(Chapter 9(crmmcreingwith Section 7000)of Division3 ofthc Business and Professions Code)or that he Is exempt therefrom and GTY. PLUMBING PERMIT
¢
¢ Fo. the basis For tbcallcg,it exemption Any violation of Bcctinn 703 L5. STORIES TYPE CONSTR.
by anyapplicant for a Pcond subjects the applicant toe civil lnnalty ALTER-DRAIN& VENT-WATER (EA.) 5.00 -�
of not more than five hundred dollars(5500).'.
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,'will do the work,and the structure is not oCC.GROUP RES UwTS
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA;COND- 5.00 .3
Code:The Contractors 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 CO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employers,provided that such improve-
mentsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-11NC.4 OUTLETS 6.00
ke or improvernopt is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burcen of proving that he did not build'or am- - . -
prove for purposeofsale.). INDUSTRIAL WASTE INTER.' 30.00
RES 'IND . CON , PB Care,
ID as owner of the property,am exclusively contracting with Ley ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-11 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who hudds or improv s thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projccte wffr a contra tons)liccowd pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the COntmetora License Low. TRACT NO. PARCEL NO.
❑ l am exempt Linda Sec.-,BAP.C.for thisreason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKIERS'COMPENSA'VION DECLARATION WATER TREATING EQUIP. 5.00
I hereby.,firm that 1 have a certificate of consent to self-insure. 7r 0 ZONING
or a certificate of Workers Compensation Insurance,or a certified ENG,SITE NO.
copy thereof(See 3800,Wh.C) -
Policy No: Company
0 ❑ Certiticdco is hereby furnished-
jp FIRE SPRINK ENERGY T T4
Z_ Z ❑ Certified epy is tiled ith tsC'city inspection division. MISC.- REFER TO ORD.
0 _ APOIic t o q- V ❑ N❑ Y ❑ N❑
~ y - PERMIT ISSUANCE 10.00 t FLOOD ZONE AL.UGc
CESRTIP_ICATIi OF EXEMPTION FROM WORKERS' 2 VV
W J - COMPENSATION INSURANCE. PLG.CONTE. LIC.NO. PLG. Q
CL 0 H his .suction need not be completed if the pertain is for one TOTAL /r V❑ N❑. Y ❑ NO
Z) Z hundred dollars IS l W)or less.)
0 O I certify that in the pedormancc of the work for which this per- GTY. MECHANICAL PERMIT FEE - FEE SUMMARY
U- f mit is issued;1 shall not empley any person in any manner w as to
U become subject to the Workers Compensition haws of California.
a Date Applicant - BUILDING 70-
OU
>7w NOTICE TO APPLICANT: If,after making ads Certificate of Ex- ALTER OR ADD TO MECH. 5.00
I- Z emption,you should become subject to the Worloon'Compensumn APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you Licit forthwith comply with FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10MOCF.NL) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=CF.M.) 6.00 SEISMIC FEE
1 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(Sec. MICROFILM
3097,Civ.C.). s HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's No HEATING UNIT(OVER 100,000 B.T.U.19.50 Q
Lenders Address ELECTRIC
I certify,that l have read this application and star,that the above VENTILATION FAN (SINGLE) 4.00
information is correct 1 agree to comply witnall city and county - PLUMBING
ordinances and state laws relating no building construction, and BOILER-C 13(H.P.Dr100,000B.T.U.) 6.00
hereby authorize reprecmatives of this city.tn carer upon the BOILER-COMP (Over 100,000BTU)SEE FEE SCH. MECHANICAL 4�-
above,machoned property for inspection purposes.y. 04
(We) agree to save, indemnify and keep harmless the City of misc.- REFER TO ORD. s
uportito against liabilities,judgments, costs'and expenses which PERMIT ISSUANCE 10.00 ♦ll9 CONST.TAX 3 7
nay in a way accrue against said City in consequence of the
,ling this pe'mit. MECH.CONT, LIG NO, MECH
TOTAL•" C/G TOTAL
am �/reo Applicant/Contractor Date �II / a �
OFFICE COPY