3346 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI.. POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION ERM BER
BUILDING APPLICATION & PERMIT /�
�( ADDRESS `t
d BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OwrvEP'a _ -v*' PLAN CHECK VALIDATION
AME CITY. ELECTRIC PERMIT.; ;FEE.,
CO
4A hl,
TRACTOR UTLETS-SWITCHES-RECEP 5.00/1,00
-//✓�//K/ •,rvo Q� LIGHTI NG F IXTURES 5.00/1.00
P, NTRACTOR'a y PPLIANCES•RESIDENTIAL 4,00
AOOqRE�aastass 77
27%09 vHONE �0 PANELS 5.00 DATE OF APPLICATION
ARCHITECT 6.00 PLAN CHECK FEE P.C.NO.
on SIGNS
ENGINEER
' sec,NO SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIALCIRCUIT 5,00ADDRPERMIT VALIDATION
SS
ZIP TEMP.METER OR POLE INS. 15.00 /I
ADDRESS MOTORS SEE FEE SCH. l Ji/j7
ADDRESS
SERVICE CHANGE 10.00 �ci
Woo LICENSED CONTRACTORS DECLARATION � �6 J
s U u I hereby affirm that 1 am licensed under provisions of Chapter 9 I55u NCE ATE
-2 p1 (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
FD / Professions Co my license is in full to f IL- ❑ ❑ ❑
0 --` Licen a Lic.Number
w Date Contractor
x s T1, ILDING PERMIT-X,;s,
tr w u O NER-BUILDER DECLARATION r y*f.J,aINFORMATION,,,�
LL vi I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD A I N S/FT.
w 0 Law for the following reason.(Sec.703 1.5,Business and Professions PERMIT ISSUANCE 6.00
m0 Code:Any city orcounty which requires a permit to construct,al ter,
In a improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONT". LIC.NO. ELEC.ac M
O M requires the applicant for such permit to file a signed statement that TOTAL o Upe IRV MIT TO
w 9 x he u Iittnxd pursuant to the provisions of the Contactor i License ..
Law(Chapter9(commencing with Section 7000)of Division 3 ofthe - d'•` r, .tF�LOO� a
Businrn and Professions Code)Gr that he is exempt therefrom and CITY 1:' {.PLUMBING PERMIT 'i- Tae r'st( xFEE`
¢ H� the basis for the alleged exemption.Any violation of8ection 703 t.5 :+Ci - ; `'�_ „ a.•� 'y iYTy3,4 STORIES TYPE CONSTR.
by any applicant for a permit objects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00 A4&6.
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 occ. OUP RES.UNITS
their sole compensation,will do the work,and the structure is not .!A�V Z ai
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 FIXTURES-PER TRAP 4.00 50.FT.FLOOR AREA TOTAL ACREAGE
himselfornot hrough
oroffenoyees, e.I f,ed that however,
the
improve- GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
meats arc not intended o n employees,
ee sale.If,however,tha building
or improvement is sold within one year of completion,the owner- GAS•EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Olna,
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ [,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. 5.00 ASSESSORSPARCELNO.
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 the Contract suchLicenectawith acomranorts)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the Contractor's s License Law.
❑ lam exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.-DATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that 1 have a certificate ofcoment to scif-insure. ZONING ENG.SITE NO.
or a certificate of Workeri Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z O ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
Applicant Y N Y N
~ H PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
CC CERTIFICATE OF EXEMPTION FROM WORKERS'
LU - COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ N❑ v❑ N❑
d (This Pectic. need not be completed if the permit is for one TOTAL
� Z hundred dollars IS 100)or less.) •-.
U O 1 certify that in the performan the work for w ich this per- OTV. , f MECHANICAL'PERMIT;: - " FEE •<FEE SUMMARY "
Ey.. mit is ns d,1 hall not employ person in any ner. as to
LL U hec It Workers' ens tion f r i. �. '
0 w Date Applicant ALTER OR ADD TO MECH. J4.00 BUILDING N
} NO T A LICANT: If, er m Ing this rtificate of Ex-
~ ? empti.n,y should become ject t e Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Co e, you most forthwith comply with FEE
L.7 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=r-F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10400C.F.M.) 5.00 SEISMIC FEE ar
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,Civ.C.). - HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name H EATI NG UN IT(OV ER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that I have r�aiipplicatlon and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. aBBTT�B1ff��16 inpl with all city and c...4
y BOILER•COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorise representatives of this city to anter upon the BOILER-COMP ID.,100,000 BTU)SEE FEE SCH. MECHANICAL
aboveP.g1p
operty for inspection purposes.
(Wve. indemnifyand keep harmless the City of MISC.• REFER TO ORD.
Curtabilities,judgments, costs and expenses which CONST.TAX
may iccrue againsts ' City in co •quence of the PERMIT ISSUANCE 3.00Bra0liit. MECH.CONT. LIC.NO. MUCH
Y TOTAL' '? .��
Sign re I'Applican[ etmet ale _ :'r+'
OFFICE COPY