17696 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENT]FICATI ON PERMIT NUMBER
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OAPPLICATION & PERMIT 17696
DRESS
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN-CHECK
• NAMEA Y`O QTY. ELECTRIC PERMIT FEE
C �S C4 I-1ASS0 PRONE 0)-
CONTRACTORS OUTLETS-SWITCHES-RECEP 10.0011.00
NAME �1 _
KS /Q FpIfICnL J-A)- UCNO.✓�.1'363(i LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S1FN>•q PPLIANCES-RESIDENTIAL 4.00
ADDRESS
,�4a1 7 ,'�l=01DO PHONE y!, R fjO PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER tic.No. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIALCIRCUIT 5.00
PERMIT VALIDATION
ADDRESS
nP
EMP.METER OR POLE INS. 20.00 ��_ I7r�;�
L
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS I
SERVICE CHANGE 20.00 � /,y11-��WUNCU
'09
0o LICENSE CONTRACTORS DECLARATION t
a c W I hereby affirm H
that 1 am licensed under provisions of Chapter 9 -� ISSUANCE DATE
H< H (commenting with Section 7000)of Division 3 of the Business and BLDGPLG.. ELECT. M .
F m z Professions Coy and y,license is in fall force and effect - fs
z o In - License ass`Q`T Lic.Numbar.l...[ +?j& ❑ ❑ ❑ be
o a D Date t ContmCWr ( ' ..
it y O s w yy BUILDING PERMIT
E w OWNER-BUILDER DECLARATfOS�u�y INFORMATION
w3 u of 1 hereby affirm that 1 am exempt from the Contractors License MISC.- �7tR REFER`f0 ORD
u o¢ Law for the following reason.(Sec.7031.5.Businessmd Professions PERMIT ISSUANCE 10.00 VALUATION 5/FT.
r - A Code:Any city or county which requires a permit to construct,alter,
a,G Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
K
m he is licensed pursuant to the provisions of the Contractor's License
E, za
Law(Chapter 9(commencing with Section 7000)at Division3 cribs
Business and Professions Code)or it,.,he isexempt therefrom and DTV. PLUMBING PERMIT FEE
at r es the basis for the alleged exemption.Any violation of Section 7031.5 STORIES YPE CONSTR.
i3 - by any applicant for a permitsubjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work.and the stRactere is not
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 imprmes thereo,and who docs such Wolk FIXTURES-PER TRAP SUL FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided that such improve- GAS-EA.SYSTEM-1 IN .4 OUTLETS 6.00
ments are not intended or offered for sale.If,however,the building
or improvement is Sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 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.). INDUSTRIALWASTE IN ER. 30.00
❑ I,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 ASSESSORSPARCEL NO.
and Professions Cade: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 contractoHs)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 --TRACT-NO. PARCEL NO.
the Contractor's License Law.
0 lam exempt under Sec .B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACL.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I M1Jvc aCerll(ICaIC Of C0ns1'm tO Self-In5ar0. ZONING ENG.SITE NO.
or A certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab )).C. Iqt. nM/ P p
Policy NO a'a!)RO Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z 'k Certified copy is filed with lbs city ire,ovn division. MISC.- REFER TO ORD. YN❑ Y C] ND
Applicant
F- PERMIT ISSUANCE 10.00 FLOOD ZONE AL.U.C.
(r - CERTIFICATE OF EXEMPTION PROM WORKERS'
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y N❑
CL ❑ (This section 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 performance of the work for which this per- OTy. - MECHANICAL PERMIT FEE
IL H FEE SUMMARY
mit is issued,I shall not employ any person in any manner so as to
Ow become subject to the Workers'Compensation Laws of California. BUILDING
Date Applicant ALTER OR ADD TO MECH. 5.00
}
to NOTICE. TO APPLICANT: If,after making this Certificate of Ex-
F ? emption,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith Comply with AIR HANDLING UNIT(T010A00GF.NL) 4.00 FEE
(.J such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IOMC.F.M.) 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.CN CJl 7,00
Lender's Name H EAT]N G UN IT IOV ER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
• 1 certify End I have read this application and lite teat the above VENTILATION FAN (SINGLE) 4.00 PLUMBING
inliornution is correct. I agree to comply with all city and county BOILER-COMPO H.P.or 100,000 B.T.U.) 6.00 ��
ordinances and slate laws relating to building Construction, and
hereby authorise representatives Or this City to enter upon lire BOILER-COMP (Dear 100,000 BTU)SEE FEESCH. MECHANICAL
above-mentioned property I'or inspection purposes. r
(we) agme to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
uPertino against liabilities,judgments. costs and expenses which PERMIT ISSUANCE 10.00 .00 CONST.TAX
may in anY wuY accrue against said City in conuyuence nl the
ranting of this permit, /t MECH.CONT. LIC.NO. TECH. 0.
rl�T/-l� �` 'J C TOTAL V;� TOTAL
t, 1 h1G n Ar/ SSS 6 3 6 DS7Q
Signature of Applicant/Contract G Uu0.• C
OFFICE COPY