11559 (2) APPLICANT TQ FILLPIN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
BU I LD1 NG PROJECT I DENTI FIC PERMIT NUMBER
BUILDING APPLICATION & PE T
ADOREss
c2bs BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
d /LL
OwNER'S PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEL
l�/A`/ PHONE -
CONTRACTORS
NAME P (/ OUTLETS-SWITCHES-RECEP 10.00/1.00
B,Qy'�f/L 11 / 3s�s LIGHTING FIXTURES 10.00/1.00
sec.rvo.
CONTRACTORS pp LIANCES-RESIDENTIAL 4.00
ADDRESSr /
/ /l(" l PHONE.25 -P (> Z, IPANELS 10.00 I DATE OF APPLICATION
onncHITECT PANELS (OVER 200 AMP) 20.00 ' ,0 PLAN CHECK FEE P.C.NO.
ENGINEER
' sec.No. SIGNS TRANS. 3.00 '
ARCH.OR ENG. SPECIAL CIRCUIT 55,00 S- PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 20.00
AMOTORS SEE FEE SCH.
ADDRESSDDRESS
SERVICE CHANGE � 20.00 ✓/K` V/Yq
w 0 o LICENSED CONTRACTORS DECLARATION �p,�lG_
<U v 1 hereby affirm that I am licensed under provisions of Chapter 9 _ uly IssUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and - BLDG. ELECT. PLG. MECH.
0 E]
i Professions Code,and my license is in full f it e e O
x i ru_3 o License Class e /Z Lic.Numbe JUL J
V- Date 9L Contractor
�'- Q� BUILDING PERMIT
or; 2 w¢ OWNER-BUILDER DECLARATION _
u MISC.- R INFORMATION
K 3 A y I hereby affirm that I am exempt from the Contractor's License
FLL'oj Law for the following reason. 7031.5,Business and Professions PERMIT ISSUANCE. 10.00 VALUATION '$/FT.
Code:Any city or county which requires a permit to construct,alter,
ac Q s-Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONIR. LIC. O. / ELEG
a 0 u requires the applicant far such permit fo file a signed sm[ement that /L 6 � 3l�bs TOTAL/9 PERMIT TO
F
$ he is licensed pursuant to the provisions of the Contractor's License ELrZ�
iii Law(Chapter 9(commencing with Section 7000)ofDivision 3 0""'f ¢ o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ H S the basis for the alleged exemption.Any violation of5ection 7031.5 STORIES TYPE CONSTR.
a.'aby any applicant for a permit subjects the applicant no civil penalty ALTER-DRAIN IEA.) 5.00
of not more than five hundred dollars($500).1:
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 Oce.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is nut
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
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 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SVSTEM-1 6.00
mems are not intended or offered for sale.IF,however,the building
or improvement is sod within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving Ilett he did not buil or im- - RES IND CON PR Other
P
rove for purpose oriole.) INDUSTRIALWASTE INTER. 30.00
❑ 1,as owner of the properly,am exclusively contracting with El 0 El
licensed contractors to construct the project(Sea 7044,Business LAWN SPRINKLERS-1 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 builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a mntractons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200tt/10.00 TRACT NO, PARCEL NO.
❑ l am exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.OATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofconsent to self-insure, ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy Ilo reof lSec.3800,Lah.C.).
Policy No. Company
O ❑ Certified copy is hereby rushed. FIRESPRINK ENERGY T-24
Z Z ❑ Certif o y file wit he cit roti.. division._
O pp". tt
A ^ ter MISC.- REFER TO ORD. v NO v NNEIFy PERMITISSUANCE 10.00 FLOOD ZONE A.L.D.c.
CERTIFICATE OF I:XEMPTION FROM
LLI > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
1 (This section need not be completed.if the permit is for one TOTAL Y❑ N� Y ❑ N❑
::) Z hundred dollars Ci 100)or less)
U 0 1 certify that in the performance of the work for which this per- CITY MECHANICAL PERMIT FEE FEE SUMMARY
U_ F mit is issued,1 shall not employ any person in any manner So as to
U become subject to the Workers'Compensation Laws of California.
i Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of F.x-
f" Z emption,you should become subject to the Workers'Compensation 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 10AMC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.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. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.C.).
Lender's Name HEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC 9
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct.1 agree to comply with all city and county PLUMBING
lie ordinances and state laws relating to building constrtion, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to uc
enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
copert against liabilities,judgments,costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
m m y way see amxt said City in consequence of the
g n[in f[hisp rl MECH.CONT. LIC.NO. MECH.
a9-�Q TOTAL TOTAL
nature 4f Applicant/CDate
OFFICE COPY