5633 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES'- USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION "APPLICATION Sl PERMIT PERMIT NUMBER
BUILDINGI
I/x/(v1 ADDRESS
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BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 5633
wNER'W PLAN CHECK VALIDATION
,NAA/M--EE1 /,,/ NA u. r
/✓D at s n � - 4(4 I� QTY: ELECTRIC PERMIT 'FEE
�• CONTRACTORS ,
NAME / - ..��-y�"��� 92,n UTLETS-SWITCHES-RECEP 5.00/1.00
�I(I��14 i& /r* ac.N . LIGHTING FIXTURES 5.00/1.00
10.TRACTORc•s •, ,,�.�_, APPLIANCES-RESIDENTIAL 4.00
nmR_ SY 4 .d�/ 38-,1500
LLTE oNE PANELS 5.00 DATE OF APPLICATION
ORRCHrtECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER - '
LIC.No, SIGNS TRANS. 3.00
moo ESS OR ENE SPECIAL CIRCUIT 5.0Q PERMIT VALIDATION
Z;P rrEMP.METER.OR POLE INS. 15.00 ,
ADDRESNrs MOTORS SEE FEE SCH. 1 ��/
ADDRESS
SERVICE CHANGE 10.00
w
00 ,LICENSED CONTRACTORS DECLARATION
Q U U herby,affirm that 1 am licensed under provisions of Chapter 9 I A E D E
w z w (commencing with Section 7000)of Division 3 of the Business and
¢y BLDG. CT. PLG. MECH.
r 0 2 Professions Code,unA my license is io full fnlyepydest�/q ❑ ❑ ❑
Z o ui - License Dass Lic. ra cbe
9 y'r Contractor '
< x BUILDING-PERMIT e"'^'
a undr cnYccit orymurea w (Ser. 0 sLDER o RATION a ELEC. ENRMIT ISSUANCEIC.NO, REFER TO 600 �gL�NF�RMATI,O'N SIFT.
- mow
K 0 A I hereby affirm Ilial I am exempt from the Contractor's LicenseORD
LL 0 ¢ Law for the following reason.(Sec.7031.5,Business and Professions
w y y y q permit to construct,alter,
O limy ,demolish,or repair an structure,prior to its issuance.alsoLEC. -
O u requires the applicant for such permit to file a signed statement that TOTAL
n w m hth
e is licensed pursuant to e Provisions of the Contractor's License gPERMIT TO
I �
z i Law.(Chapter 9(commencing with Section 7000)of Division 3 ofthe
i o Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT "FEE'.
lEHmthe basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
u ; - by any uppliumajor u permit Subjects the applicant to a civil penally ALTER-DRAIN (EA.) 4.00
of not mom than five hundred dollars($500).): -
❑ 1„as owner of the Property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 4.00 i SO.FT.FLOOR AREA TOTAL ACREAGE
. himullor through his own employees,provided that such improve.
menu are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or improvement is Sold within one year of completion,the owner- ,GAS-EA.SYSTEM-OVER 4 (EA.) 7,0p BUILDING USE
builder will have the burden of Proving that he did not build or im- RES IND CON PB Omar
prove for purpose of sale.). INDUSTRIAL WASTE INTER.
O I,as owner of the property,am exclusively contracting with 20.00 ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. . 5.00 ASSESSORSPARCEL NO.
and Professions Code:The Contractor'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 projects se Law.ewith a comractorts)licensed Pursuant to
cen
the Contractor's h SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. .PARCEL NO.
❑ lam exempt unJer Sec. ,U.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPISNSA'fION OF
CLARATION WATER TREATING EQUIP. 4.00
1 here alfirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a cur f-at•of Workeri Com •nsation Insurance,o n certifieA
copy Ih' Lab.C.)
Policy m Pony- I.
0 O Certi- J C y i erehy furni
FIRE SPRINK ENERGY T-24
Z Z Ce diel p I' i •A x i i iv" MISC.- - REFER TO ORD.
Q APPIic' Y ❑ N❑ Y ❑ N❑
jr- y FICATE 01'EXEMPTION FROM WORKERS' PERMIT•ISSUANCE 6.00 FLOOD ZONE A.L.u.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.N0. PLG.
CL Z( This action need not be completed if the Permit is for one TOTAL Y❑ N❑ Y❑ N❑
Iwndred dollars(S 100)or less.)
U 0 1 certify that in the Performance of the work for which this per, QTY. MECHANICAL PERMIT FEE FEE SUMMARY"
LL F mit is issued,I shall not employ any person in any manner so as to
OW become subject to the Workeri Compensation Laws of California.
y Date ApplicantBUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of ISA- ALTER OR ADD TO MECH. 4.00
F Z emplion,you should become subject to the Workers'Compmsutlon APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or INS permit shall be decnied revoked. AIR HANDLING UNIT(TO.10=1 .F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,CivC.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.17.50 ELECTRIC
I certify.that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
• information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) .4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP Over 100.000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) c t ve, indemnify and keep harmless the City of 'MISC.- REFER TO ORD.
caper^ o gui 'a CA
mems, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX '
y aceta a sl d City in consequence of the
V ting enni MECH.CONT. LIC.NO. MECH.
8- 2;�- y`� orA TOTAL
Sign ureol'Appicant ontructor Date
OFFICE COPY