1464 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI_ POINT PEN ONLY
PERMIT NUM ER
BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT 64
A OGRESS AN
�y/
AOOREES ,Y,I
/ , BUILDING —ELECTRICAL—PLUMBING—MECHANICAL
OWNER'S ���� \\ /NUKN rZ - r �. .:, .�"':';e '�'r^. -• PLAN CHECK VALIDATION
NAME ,I \��r I •/,"1 GTY. - ELECTRIC PERMITr 'e '- FEE
• L J /',,PHONE YF'Ib "� ✓r' .
CONTfl CT R3
• NAME OUTLETS
-SWITCHES-RECEP 5.00/1.00
LIC.No. LIGHTING FIXTURES 5.00/1.00 ._
ADDRESS APPLIANCES PPLIANCES-RESIDENTIAL 4.00
CONTRA
PHONE PANELS S.00 DATE OF APPLICATION
ARRCHITECT SIGNS 600 PLAN CHECK FEE P.C.NO.
ENGINEER
LIG.Na. SIGNS TRANS. 3.00
AARCH.OR DDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP rrEMP. METER OR POLE INS. 15.00
APLICSMOTORS SEE FEE SCH.
ADDREDDRESSS /
SERVICE CHANVft 10.00
woo LICENSED CONTRACTORS DECLARATION
< v y I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
e, n (commencing with Section 70001 of Division 3 of the Business and
H N i Professions Code,and my license is in full force and effect. BLDG. ELECT. PLG. MECH.
Z o,A— License Class Lie.Number ❑ ❑
O z r oww Date Contractor
a r S d f.'4i.VBUIL'DING'FERMITr"C-7 r,}l
x ¢ w u OWNER-BUILDER DECLARATION �:'=!'i"e`,-" INF,ORMAT,ION�' rt
'x °;LL y I hereby affirm that I am exempt from the Contractor's License MISC.— ft4EFER TO ORD - "
La ..o ve Law for the fallowing reason.(Sec.7031.5.Busimmand Professions A DATION S/FT:
H _ PERMIT ISSUANCE 6.00 \}
f sit y Code:Any city or county which requires a permit to construct,alter, L
R 2 Q D improve,demolish,o!repair any itr11C5aR,prior to its issuance,x150 ELEC.CONTR. LIC.NO. ELEC. G'
M requires the applicant for such permit to file a signed statement that TOTAL
w ?y he is licensed pursuant to the provisions of the Contractor's License .v,' t., a•;±-• t x 3K
as r Law.(Chapter 9(commencing with Section 7000)of Division 3 of the
4 c Business and Professions Code)or that he isexempt therefrom and Ory.t vv`PLUMBING PERMITy. rf LFE
M r$ the basis for the alleged exemption.Any violation of Section 7031 5 ° �. ?E s; •, eFr-.rr-'1'C x_ T CONSTR.
u; _ by any aomthafor
ive permit subjectsthe$500).licant laacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(my employees
❑ I,as owner of the property,or my employees with wages I.snot BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
(S
their sole compensation,will the work,and the structure is not
intended or offered for Lice,Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Cade: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 So.FT.FLOOR AREA TOTAL ACREAGE
himself through his own employees,Provided that such improve-
meritsare renot intended oroffered for sale.If.however.the building GAS•EA.SYSTEM-/ INC.4OUTLETS 4.00
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 RES IND CON PB Otner
im-
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 2000
❑ 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 Code:TheContractor'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 contmctons)licensed pursuant to
the Contractors Lice se Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ le de c. .BAP.C.for this WATER HEATER W/VENT 4,00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
PE I n to ON WATER TREATING EQUIP. 4.00 -
1 hereby affirm that I have a certificate of consent io self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y [:] N[_ Y C] N❑
~ CERTIFICATE
�+ PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.L.
Lu COMPENSATION
EXEMPTION FROM WORKERS'
W � INSURANCE PLG CONTR. LIC NO. PLG.
d O (This section need not be completed if the permit is for one TOTAL Y❑ IN E:] Y❑ IN
V O hist eerttifyred olttars(I hat in h01 orless.)
of the work for which this er. Ik. : .� �,> •++'i+ 111'.'t'i`p( y.e ' 1' i� / s . E
v v OTY. 'MECHANICAL PERMIT, W. FEE • s.;�.tFEE SUMMARY
LL f mit is issued,1 shall not employ any person in any manner so as to
O w become subject to the Workers'Compensation Laws of California. r
Go Date Applicant BUILDING (J
} N NOTICE TO APPLICANT: If,after making this Certificate at Ex- ALTER OR ADD TO MECH. 4.00
I-' ? emptied,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK 3 �arP3
provisions of the Labor Cade, you must forthwith comply with FEE
such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 14000 C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 5.00 SEISMIC FEE d-a.
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 ISee, MICROFILM
3097.CNCA HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name - HEATING UNIT 100,000 B.T.U.)7.50 �T
Lenders Add,ev ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER•COMP I3 H.P.or 100,000 B.T.U.) 4.00
h ay aulhotize representatives of this city to enter upon the BOILER-COMP Over 100,000 BTU)SEE FEESCH. MECHANICAL
--mentioned property for inspection purposes.
'e1 agree to save. indemnify and keep harmless the City of MISC.- REFER TO ORD.
n against liabilities,)udgmen osis and expenses which CONST.TAX
qqga y way accryp agm Ci in can a of the PERMIT ISSUANCE 3.00
( o this permit, 2 ECH.CONT. MECH. s 3v;m a
— 2 TOTAL t*St'IY I- Mr1,lih;,P,} �� 3
,YI,TOTAL yy
I •o pplieant m 40 Dam ;
OFFICE COPY