5657 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -.USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMITNUMBER
BUILDING APPLICATION & PERMIT 5657
ADDRESS
yr V BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
IJ r
OwrvER'S / �..5 PLAN CHECK VALIDATION
_ OTY. ELECTRIC PERMIT FE E.
PHONE
Co FA o"s OUTLETS-SWITCHES-RECEP 5.00/1.00
NA1?pp �1
x V 0 e o dD�k 7 LIGHTING FIXTURES 5.00/1.00 -
r. NTRAcroe's da/ PPLIANCES-RESIDENTIAL 4.00
A Eoc 1 l )
PHONE f L PANELS 5.00 DATE OF APPLICATION
RC ECT SIGNS - 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER '3.00
'sec.No. SIGNS TRANS.
ARCH.OR ENO. 5.00 P HM LIGATION
ADOHEss SPECIALCIRCUIT
ZIP EMP.METER OR POLE INS. 15.00
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00 -7 ' I
Doi
Foo LICENSED CONTRACTORS USCI-ARATION
a u v I Imrehy allirm that I am licensed under provisions of CbxpW,9 ISSUANCE DATE
a<w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F w .P.fessiom C9yfe nd I liccense is in full force
i o w - icon.Clas(i-c(Lf --c r Lie Number ❑ ❑ ❑ ❑
9 F o Uatc_yfRContracmr
a ! OO '+{BUIL"DING)PERMIT
p Ii w U OWNIi R-BUILUIiR DGCLARA' 10 ''!`1,Y,IN F�ORMAITION .
In IL N 1 hereby affirm that I am exempt from the Contracmr's License M ISC.- REFER TO ORD
..o a Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE LUATION S/FT.
L• - Codec Any city orcounty whichmquimsapermit toconslruol,alter, 6-�
¢¢ p improve,dcnsolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
u w m he is licensed pursuant to the provisions of the Contractor's License /�
rzi Law(Chapter 9(commencing with Section 7000)of Division3ofthc rAfp'r /S/�
a Nus Ore.and Professions Code)or that he is exempt tlmrefor and QTY- PLUMBING PERMIT 'WT7
r Go the basis for the alleged exemption,Any violation ufSection 7031.5 TYPE CONSTR.
a ;m by any applicant for a permit subjects the applicant loacivilpenally gLTER-DRAIN&VENT-WATER (EA.) 4.00 '
of not more Than five hundred dollars(S500)J:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC,GROUP RES.UNITS
Ibcir sell,compensation,will du the work,and the structure is not
intended or GIRmd for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code The Contractors License Law docs not apply to an owner of
property who builds or improves themon,and who does such work F IXTUR ES-PER TRAP 4.00 so.FT.FLOOR AREA TOTAL ACREAGE
incurs
lam rmlthrugh intends ownemployees,for sale.
If,
however,the
improve..
buildig GAS.EA.SYSTEM-11NC.4 OUTLETS 4.00
mems are not intended or offered for sale,If,ed that s the 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 On.,
prove for purpose of vlc.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑ ❑
❑ 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. 5.00 ASSESSORS PARCEL NO.
and Professions Codc: I he Contractor's License Law docs 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 contracted%)licensed pursuant to
the Corolmcmr'�Licenu Law. _ SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.I'or this WATER HEATER W/VENT 4.00
son
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPF-NSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby Alit. that I have a ccifificilm of consent m sell'-insure. ZONING ENG.SITE NO.
or c'-rrttiiff'i'cate offjW/gorkers'Compenc
ution Ins c,or a certified
CCompany
Q ❑ Certified c py Is hereby tumished. FIRE SPRINK ENERGY T-24
Z_ Z ❑ Certil'ie op s li - with city inspection division. MISC_ REFER TO ORD. Y ❑ N❑ Y ❑ N❑
Applicant
CCPERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
� - Cfi IFICAI PICCOI OP EAI IO FINS FROM WORKERS'
w > COMI'IiNSAT'ION INSURANCE PLG.CONTR. LIC.NO. PLG. v❑ N❑ Y ❑ N❑
a O fI'he, section need nut be completed if the permit is for o TOTAL
Z hundred dollars(S 100)or less.) of -
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE O FEE SUMMARY
LL P mil is issued,I shall net employ any person in any manner so as to `/
O W become suhlect to the Workers'Cnmpcmatinn Laws of Cililbrnia. BUILDING IJ ((Js�
para licant ALTER OR ADD TO MECH. 4.00
>_ y AppNOTICE APPLICANT: If,after making this Certificate of F:x-
F ? ent'hm,you should become subject us the Workcrs Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10p00C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 1000C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a Construction lending agency far EXHAUST HOOD (WITH DUCT) 2.00
the perl'onnance,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 HEATINGUNIT OVER 100,000B.T.U.)7.50 ELECTRIC
Lender's Address
I certily that I have read this application andstate that the above VENTILATION FAN (SINGLE) 3.00
information is curn'.el. 1 agree to comply with all city send county BOILER-COMP 13 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby aulhori, representatives of this city to enter upon the BOILER-COMP(Over 100,0000TU)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.
Cuper' against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may n u y way accrue against said City in consequence of the
gra in fl ism➢i MECH.CONT. LIC.NO. MECN.
TOTAL TOTAL S
Signature of Applicant/Contractor Date /
OFFICE COPY