11858 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY'
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
UUILDIN6 APPLICATION & PERMIT
ADDR Ess
BUILDING-ELECTRICAL-PLUMBING -MECHANICAL 11858
.1044) W lea
IWNER'S PLAN CHECK VALIDATION
( OTV. _ELECTRIC PERMIT FEE !PXONE
RP DR'S E OUTLETS-SWITCHES-RECEP '10.00/1.00
LIC.NO. LIGHTING FIXTURES 10.00/1.00
ADDRESS DR's - PPLIANCES-RESIDENTIAL 4.00
CONTRA
HONE r_rJ_gY4 PANELS 10.00 DATE OF APPLICATION
cHI C
OR _ PANELS(OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
' „
ENGINEER
- LIC.No. SIGNS TRANS. I 3.00
ARCH.OR ENG. - SPECIAL CIRCUIT 5,00 PERMIT VALIDATION•'
ADDRESS
ZIP TEMP.METER OR POLE INS. 20.00
ANT'$ MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE - 20.00 -
- D 0 2 LICENSED CONTRACTORS DECLARATION
a u 1 hereby affirm that I am licensed under provisions of Chaplet 9 (� y/I(- ISSUANCE DATE
in < N (commencing with Section 7000)of Division 3 of the Business and SLOG. ELECT. PLG. MECH.
r m z rofessions Code,and my license is in full force J eff t. El El El
O m - License Class Lic.Number
o'er r 0 Dale=lContractor
a y s �t BUILDING PERMIT
wu OWNER-BUILDER DF-CIARA'1'ION - INFORMATION
w3 LL n '1 hereby affirm that I am exempt from the Contractor's License MISC._ REFER TO ORD
u O ¢ Law forthe following reason.(Sec.7031,5,Business and Professions PERMIT ISSUANCE - 10.00 - VALUATION S/FT.
rN ✓+ � Code:Any city orcounty which requires a permit to construct,alter, -
K 2
40 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. -LIC.NO. ELEC.
ca
F 0,
requires the applicant for such permit to file a signed statement(hat TOTAL PERMIT TO
a m he is licensed pursuant to the provisions of the Contractor's License .S
au 0 Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
f z o Business and Professions Code)Or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
s- the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d ; by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAINI&VENT-WATER (EA.) 5.06
of not more than five hundred dollars($500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4,00 OCC.GROUP - RES.UNITS
-•heir sale compensation,will da the work,and the structureis no[
/ inded or offered for eole'(Sce. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CONDI 5.00
The Contractor's License Law dues not apply to an owner of 1
( luty who builds or improves thereon,and who does such work FIXTURES-PER TRAP Q
I . 5:00 SFT.FLOOR AREA TOTALACREAGE
h If or through his own employees,provided that such improve- \
i t are not intended or offered for sale.II',however.the huildon, GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
.tptovement is sold within one year of completion,the owner-
_ GAS-EA.SYSTEM'-OVER 4 (EA.) 2,00 " BUILDING USE
,IAer will.have the burden Of proving that he did not build or int- RES IND ON PB Other
prove for purpose of sale.).' INDUSTRIAL WASTE INTER. 30.00
IJ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ - ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. ,-6.00 A55E550115 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 contractors)licensed Purstmnt to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ l am exempt under Sec. ,H,&P.C.far this WATER HEATER WN ��; 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKF-RS'COMPF-NSATION DECLARATION WATER TREATING)E UIP. J,, J 5.00
I hereby affirm that I have a certificate ofconsent to self-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified SITE N0.
,copy thereof(Sec.3800,Lab.C.). 3 i1U WaSIQ Ino
olicy No. - Company
❑ Certified copy ishereby furnish �LY FIRE SPRINK ENERGY T-24
Z Z" ❑ Ccr d c Is Bled with ne cify inspect Oil division.
p Applicant � y_��- MISC.- REFER TO ORD. Y ❑ No Y ❑ N❑
to CERTIFICATE 017 EXEMPTION 17ROM WORKERS' PERMIT ISSUANCE - 10,00116
FLOOD ZONEA.L.U.C.
L � COMPENSATION INSURANCE PLG.CONTR. UC.NO. - PLG
1 . n/I-c.t ❑ ❑ ❑ ❑
0 (This section need not be completed if the permit is for one TOTAL LJ-C/ V IN V N
:_1 Z hundred loll ars($1001 or less)
U O I certify that in the performance of the work for which this Ver- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
L F mit is issued,1 shall not employ any person in any manner so as to
U/ becolryry bje to tire Workers' pensati Lyyyy}}gg Califona.
0 Datc�),t�Applicam -/F� ALTER OR ADD TO MECH. 5.00 _ BUILDING
Ul NOT CC LICANT: If,after naki his Certificate of lix-
♦- Z amp ion ou should become subject to the Workers'Compensation APPLIANCE .5.00 PLAN CHECK
U suchlprovisionstile
or thsbpermior Code,
i shall be deemed relwith voked comply with AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCYAIR HANDLING UNIT(OVER 10MC.FM.) 6.00 SEISMIC FEE
I 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 HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
•ndcr's Address'
certify that I have read this application and slate that the above VENTILATION FAN JSINGLE) 4.00
I motion is correct. I agree to comply with all cify anJ c..uy PLUMBING
( anew and state laws relating to building Construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
iy outhorire representatives'of this city to enter upon the
ie-mentioned properly for inspection purpBOILER-COMP'IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
j h nms. -
�(We) agree to save, indemnify and keep harmless tiro City of MISC. .REFER TO ORD.
JaSignat
no against liabilities,judgments, costs and expenseswhichCONST.TAX
any way-accrue against saiin consequence of the PERMIT ISSUANCE 10.00
of this pc it. ) MECH,CONT. LIC.NO. MECH.OTALTOTAL
s'of A Pelican(/61 ractor at
' OFFICE COPY'