17816 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES = USE BALLPOINT PEN ONLY
BU LD1 NG PROJECT IDENTIFICATION. PERMIT NUMBER
aDILDING APPLICATION & PERMIT '= ^ 17816'
ADDRESS)&Bin _ A;oTS t 7 l! i'C1
UILDING - ELECTRICAL-PLUMBING -MECHANICAL
OwNER'91� 1e PLAN CHECK VALIDATION
NAME 1-H1�1 f- OTV. ELECTRIC PERMIT FEE
_ -s PHDN�339�4�
NAMECONTRACTORs 2kyy/ /1/7 UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO LIGHTING FIXTURES 10.00/1.00
DNr AcrORs
AO REss PPLIANCES-RESIDENTIAL 4.00 '
A
e PHONE PANELS 10.00
DATE OF APPLICATION
OAITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE .C. O.
ENGINEER -
uONo, SIGNS TRANS. 3.00
AARC R DDRESS ENG, SPECIAL CIRCUIT •5.00 PERMIT VALIDATION
ZIP ITEMP.METER OR POLE INS. 20.00
Avvucwers MOTORS SEE FEE'SCH. t-
AooREss `
SERVICE CHANGE 20.00
Foo LICENSED CONTRACTORS DECLARATION ' i -�
a v w 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y¢ y (commeactna with Section 7000)of Division 3 of the Business and uvJU BLDG. ELECT. PLG. MECH.
F m z Professions Code,and my license is in full force and effect. _ T '� �✓
Z o m - License ClassLie.Number �; t
0 z w Date Contractor I'
a x s 1111P.1tIDD BUILDING PERMIT
rt w o OWNER-BUILDER DECL\RA'f10N INFORMATION
u`xv o a s- I hereby affirm that 1 um exempt from the Contractor's License MISC.- REFER TO ORD
U. I� - VALUATION $/FT.
F .. oat law for the following reason.(Sec.7031.5.Ifusinusand Professions PERMIT ISSUANCE '10.00
� n , I Code:Any city or county which requiresa permit toconstruct,alter, IIO� 127 esop
a, Q o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. O �kJ
O LL requires the applicant for such permit to Ole a signed statement Thal TOTAL 5 PERMIT TO
a w m y he is licensed pumant to the provisions of the Contractor's License
Fz >
Law(Chapter9(commenciagwith Section 1000)of Division 3 of the
a Business and Professions Cale)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE NI L/V-s
0 the basis for the alleged exemption.An
g p he violation of Sec tion malty STORIES TYPE CONSTR.
a by any applicant fora permit subjects the applicant toacivil penalty
of not more ALTER- AIN&V ENT-WATER (EA.) 5.00
' a than five hundred dollorsl5500).]:
❑ 1,as owner of the property,or my employees with wages as BA FOW PROTECT.DEVICE 4.00 DEC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure Is not
intended or offered for sale(Sec. 7044, Busincv and Professions Q01N - R,ROOF,AREA,CONO. 5.00 - t7-'ZZ,)
Code:The Contractor's License law docs not apply to an owner of f
property who builds or improves thereon,and who does such work FIXTURES- AP '5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.Provided 0u d such imprnvo
ments ase not intended or offered for sale.If,however,the hul Wing GA _SYSTEMO IN OUTLETS 6.00 I G -7 8
or'mprovemcnt Is sold within one year of completion,the owner- GAS-E EM-O 4 IEA.1 2.00 - ✓ e//UILDING USE
builder will have the burden of proving that he did not build or iln. RES IND CON PB Omer
prove for purpose ofsale.). IND IAL WASTE INTER. 30.00 ,...,/
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑- ❑
licensed contractors to construct the project iSec.7044,BusinessLA KLERS-1 INC 5 V.B. , 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors Licenw law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRI S-OVER 5 (EA.). :1 00 '
contracts for such projects with u contrudorfs)hocused pursuant to
the Contractor's Liccnsc Law. SEWER-SANITA RM EA.200ft/10.00 TRACT NO., PARCEL NO.
❑ 1 am exempt under See. .tl.Cd'.C.lie this WATER HEATER W/ 6.00
mason
Owncr Date WATER SYSTEM ..5.00 ACC.OATE ,ACC.FILE NO,
W❑RKERS'COMPI;NSATION DECIARA'I ION WATER TREATING EQUIP. 15.00
I.hcmhy nT,F1 that l have a ccudi,ce of concent to wlf insure, ZONING ,ENG.SITE NO.
ccertificate of Workers'Compansuliou In,suruive,ora certified
opy thereof(See.3800, .C.T - -
Policy No. Co any
O ❑ Certil Ted copy ahy ltsnushc , FIRE$PRIryK ENERGY T24
Z Z ❑ eRiMd m iv tiled with C inspection division. MISC.- REFER TO ORD.
O nFix II Y❑ N❑ V ❑ N❑
~ vat PERMIT ISSUANCE 10.00 12
2 C: sIC 70111 Xf_. O PROM WORLISRS' .FlooD zoNE A.L.u.c.
W � CONIPENSAT ION INSURANCE PLG.CONTR.- LIC.NO. PLG, GI CD ❑ - ❑ ❑ ❑
d I'fhia section aced not be completed it the pernil la lit.one - TOTAL J V N Y ry
Z hundred dollars IS 100)or less)
U O 1 certify that in the performance of me work for which this Per QTY MECHANICAL PERMIT. 'FEE FEE SUMMARY
LL U mit is issued,I shall not employ any Person io any tna neer m us to
become subject to the W'orkvu,Compensation Laws of California. [y,
Dwc - As NC,uu BUILDING
a 1 P ALTER OR ADD TO MECH. 5.00
} H NOTICE TO APPLICAMf: II,alter conking this Ceril Teale of lix-
? ensption,you should become subject to the Workers'Compensation APPLIANCE 5.DO PLAN CHECK
proviRuns of the Labor Code, you most I..fliwlth comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.). 4.00
CONSTRUCflOULFNDINCAGENCYn AIR HANDLING UNIT(OVERIQOOOC.F.M.) 6.00SEISMIC FEE 881
I hereby affirm that (here is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(See. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM --
Lender's Name H EATI NG U N IT(O V ER 100,000 B.T.U.)9.50ten
Lender's address ELECTRIC �I
I certify that l have read thisapplicut ion and slate that the above VENTILATION FAN (SINGLE) 4.00 '
ial'ommalien is correct, I agree to comply with all city and county PLUMBING
ordinances and slam laws relating to building construction, and BOILER-CONPI3 H.P.or 100,000B.T.U.1, 6.00 5�
hereby authorize representatives of this city to enter upon the BOILER-COMP e s 10„er 100,000 BTU)SEE FEE SCH. MECHANICAL 5 1
above mentioned property for inspection purpoi.
(We) agree to}esb, indemnify and keep harmless the City of MISC.- REFER TO ORD.
uperlino agai of(/abilities,judgments,costs and expenses which PERMIT ISSUANCE 10.00 `1� CONST.TAX 31J.,`-14
By in any )/accrue ainst said City in ronsn Ience of the , -+
mhng o permll. MECH.CONT. LIC.NO. MECH.
TOTAL
TOTAL (DS D,G7
I rcof Applicant/Contractor Da
OFFICE COPY