17027 (4) ,APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
PERMIT NUMBER
0111001 NQ PROJECT IDENTIFICATION . si �f f�O^Pql
E p APPLICATION &PERMIT r I I I /f
7-1 a I Qv Prow e j BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
p Ea9 PLAN CHECK VALIDATION
" .,�f/7 �' QTY. ELECTRIC PERMIT FEE
1 �, _ (�, PHONE 1 �-46 A-Z CONTRACTORS UTLETS-SWITCHES-RECEP 10.0011.00 J�i 1.3
NAME �J Jfl
LIC.NO. 'i 2 LIGHTING FIXTURES 10.00/1.00 ��
CDNmACroR'6 PPLIANCES•RESIDENTIAL 4.00
AOpRE�
w,C.•PHGNE "y,} ,-(pu gNELS 10.00 DATE OF APPLICATION -'
OR ca CT P TC tl4 PANELS (OVER 200 AMP) 20,00 PLANCHECK P,C.
W.
ENGINEER W,�Oplytl,- � SIGNSTRANS. 3.00
LIC.NO. PERMIT VALIDATION
ARMOR EN SPECIAL CIRCUIT 5•00
AoaREss
ITEMP.METER OR POLE INS. 20.00
AIMUCANITIS MOTORS SEE FEE SCH.
ADDREWy♦
r9,0 Lr� +a CtlSERVICE CHANGE
woo LICENSED CONTRACTORS DECLARATION • FLU
a iv 1 hereby air=that 1 am Licensed under provisions of Chapter 9 159U NCE GATE
Q (commencing with Sachon 7000)of Division 3 ofthe Business and BLDG. ELECT. PLO. MECH,
33 Professions Code and my license is In full force andffect.
,E o ih 2 License Ciess.�_j-_U%Number 'g�742 1 IA1 �I
t w Date A Contraeter
BUILDING PERMIT
E z w OWNER-BUILDER DECLARATION - INFORMATION
A. 3 n I hereby affmn that I am exempt frau the Contractor's License 'MISC.- EF ER O ORD q VALUATION, $/FT.
'auO law fa the following reason.(Sec.7031.5,Businessand Profeasiam PERMIT ISSUANCE X6168• IX
r y m Code:Any city or counTy which requ"uesa permit to construct.alter, hM
z ¢ improve,demolish,of rePe'v any structure,prior to its issuance,min, ELEC.CONTR. LIC.NO. ELEC. C.-L�J
u g e¢ requires the appBcent for such permit to fie a signed statement that TOTAL ays",JLJ PERMIT TO
Xhe b liaread pursuant to the provi®ora of the Confmc[or's Uwnae
Me a i [aw(Chapter 9(commencing with Section 70W)ofDfvisien3 ofthe
d UMBING PERMIT FEE
1191D
a Bovines end Anfadona Cate?a that he is exempt therefrom enQTY. PL
g ' ❑ STOflIEB TYPE CONSTR.
¢€$ the bags for the alleged exemption.Any violation of Section 70315
i g., by any eppEcant tore permit subjects the applicant toacivil penalty ALTER-DRAINSt VENT-WATER(EA.) 5.00
of not more then five Hundred do0ers($5007.7:
D I,ae owner of the property,or my employcee with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their Alla compensation,wW do the work,and the structure is not
Code:The
offered for sale(Sec. 7044, Business and Ihofes9oof DRAINS•FLAOR,ROOF,AREA,COND. 5.00
Code:The who
builds improve Lew does not apply to an owner of
propmty who buBds a improves thereon,and who does such work FIXTURES-PER TRAP .6,60 SQ PT.FLOOR ARBA TOTAL ACREAOe
hirtuelF or through his own employees,provided that such improve- GAS-EA.SYSTEM-l1NC.4 OR TS 5.00 .CO 2
mcnh are not intended oroffered fousale.If,however,the bWlding
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 CEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or M- RES IND CON PS Other
Prove for purpose of safe.). INDUSTRIAL WASTE INTER. 30.00 ❑ 11 ❑ ❑ ❑
i ❑ 1,as owner of the promperly,aexclusively contracting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 A58 660RS PARCEL NO.
end Professions Cale: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 -357-
57- 16-041
contracts for such projects with a contractor(s)licensed pursuant to SEWERSANITARY-Sl'ORM EA.200ft/10.00 7FACT No. PARCELNo.
Me Contractor's License Lew.
❑ I am exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 6.00
reason ja
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to self-inere. 20NING ENG.SITE NO.
or a certificate of Workers Compensation Insurance,a a certified
LT" copy thereof(See.3800,Lab.C.
CompanyldAeV Kir`[/
../�f
O ❑ Cert rad copy is hereby loco shed. __ --T
FIRESPRINK ENERGY T•24
ith the citREFER TO ORD.
Z Z O Certified copy is filed wy inspection division.
O Applicant MISC.• Y[I N❑ Y E] NEI
jr H CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE i45B .O FLOOD 2oNE A.LU.G.
L1J > COMPENSATION INSURANCE PLO.CONTR. LIC.NO. PLG.TOTAL y❑ N❑ Y❑ N❑
EL 93 (This section need not be completed if the permit is for one
s
M Z hundred dollms(SIOO)or lase) FEE SUMMARY
U O I certify that in the performance of the work for which this per, QTY. MECHANICAL PERMIT FEE
1F- mit is issaed,.I shall not employ any person in any manner an as to
Q W become subject to the Workers'Compensation Laws of California. BUILDING 842
Date AppOcarnI ALTER OR ADD TO MECH. 5.09
} r6n NOTICE TO APPLICANT: If,alto making this Certificate-of Ex-
� Z pre a you should become subject to the Workers Compensstbn 'APPLIANCE 5.00 PLAN CHECK
provbians of Lha Labor Code,you must forthwith comply with FEE
U such provisions or this Permit shah d
revoked. AIR HANDLING UNIT(TO 10pODGF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MCKIIA) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) - 5.00
the peperrfformance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100A00 B.T.U.) 8.00 MICROFILM
1097,CIv.C.).
header's Name HEATING UNIT(OVER 100,000 B.T.U.)6.50 ELECTRIC
Leadees Address
I certify io that!he"read I a thisin comply andwith all c that the aboveand
county -CFVENTILATION FAN(SINGLE) 4.00 . PLUMBING
information n cored.I agree to comely with all city and county
ordinances end state taws rotating to building construction,end BOILER'COMP(3 H.P.or 100,000 B.T.U.) 8.00
hereby authorize representatives of this city to enter upon the BOILER•COMP(Over 100,000 BTU)BEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes. 1
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
pordno agabut liabilities,judgments,costs and exporters which- PERMIT ISSUANCE ;6r6p CONST.TAX ...
may In any way accrue against avid City in consequence of the
of this L MECH.CONT. LIC.NO. MECH. p
c 7 1 g 70TAAAq TOTAL 7
natific of APptlwntlConttactor - Date 0 )
OFFICE COPY