10299 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -'USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON
APPLICATION &PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMITNUMBER
O ^ ^ n
BUDDING
OWNER'
NAME 'f
17,PHONE pE
DTV: ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
.06�jh,03
NAMERALTORa
UTLETS-SWITCHES -RECEP 10.0011.00
AJL-Aoee, e4 LIC. NO. /�
LIGHTING FIXTURES 10.00/1.00
w...EaiTORs Jp A)NlojCr CA,9S/aS
PPLIANCES- RESIDENTIAL 4.00
Q E PHON ,r
DATE OF APPLICATION
PANELS 10.00
OR IECT -
ENGINEER
LIC. NO.
PANELS (OVER 200 AMP)20.00
PLAN CHECK FEE P.C. No.
SIGNS TRANS. 3,00
nooseSS OR ENO
SPECIALCIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
ZIP
APPLICANT �
AOOR Ess
MOTORS '' SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.0AU
1 hereby affirm that I am licensed under provisions of Chapter 9
(Commencing Whit Section 7000) of Division 3 Of the Business and
Professions Code, and my license Is In full force and effect.
License ClassLic. Number
Is DATE
BLDG. ELECT. PLG. MECH.
❑ ❑
Data Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License
Professions
law fornycitthe llorcounty which permness it
Code: Any city or county which requirese permit to construct, alter,
to
BU_ILDING,PERMI.T; .
INFORMATION''
MISC.- REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
S/FT.
ELEC. DONTR, LIC. NO. ELEC.
TOTAL
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
PERMIT TO
Law (Chapter 9(commencing with Section 7000) of Division 3 ofthe
Business and Professions Code) Or that he isexempt therefrom and
QTY. 'PLUMBING PERMIT FEE
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (S500).):
STORIES
TYPE CONSTR.
ALTER -DRAIN -WATER (EA.) 5.00
❑ 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4,00
occ. GROUP
Res. uNlTs
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended or offered for sale (See. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
FIXTURES - PER TRAP 5.00
GAS-EA.SVSTEM-11NC.40UTLETS 6.00
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve.
menta are not intended or offered for sale. If, however, the building
SO. FT. FLOOR AREA
TOTAL ACREAGE
or improvement is sold within ane year of completion, the owner.
builder will have the burden of proving that. he did not build or on.
prove for purpose Of sale.).
❑ I, as owner of lire property, am exclusively conlructing with
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PS Other
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project (Sec. 7044, Business
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- 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCELNO:
contracts forsuch projects with a contractor(s) licensed pursuant to
the Contractor's License Law.
❑ lam exempt under Sec.., B.&P.C. for this
reason
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
-
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WORKS RS'COM PF.NSATION DECLARATION
1 hereby affirm that I have a certificate ofconsen( t0 self -insure,
or a certificate of Workers' Compete Ion Insurznce,er a certified
copy thereof (See. 3800, Lab.C.). � -W TA n J _ /CII
ZONING
ENG. SITE NO.
Policy No. Company le4wX90 111 ;2
❑ Cerlj5edTWy is hereby to nishe .
)e Car fled pY- is fhd yth the It Inspection division.
Applicant 49 .JIC�J$.� � 1-
FIRE SPRINK
Y❑ N❑
ENERGY T-24
-Y❑ N❑
MISC.- REFER TO ORD.
CERT ?IC'R mill OF'EX1 TION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U.C.
COMPENSATION INSURANCE. ,
(This section need not be completed if the permit is for one
PLG. CONTE. - LIC. NO.
PLO.
TOTAL
Y [:]N ❑
Y ❑ N ❑
hundred dollars IS 100) or less)
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ.any person in any manner so as to
QTY. ,MECHANICAL PERMIT '" '' FEE'
- ,
FEE SUMMARY
BUILDING
become subject to the Workers' Compensation Laws of California.
Date Applicant
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
APPLIANCE.00
AIR HANDLING UNIT (TO 10,000 4.00
PLAN CHECK
FEE
emption, you should become subject to the Workers'Compensulion
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shell be deemed revoked.
AIR HANDLING UNIT(OVER IO,ODOC.F
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH D 0 u 5.
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) B.
Lender's Name
Lender's Address
H EATI NG U,N IT ER 100,%.lRLmv.5o
ELECTRIC
1 certify that I have read this application and state that the above
VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
hereby entioed representatives ec this city es enter upon the
above-mentioned property for inspection purposes.
PLUMBING
BOILER-COMP(3 H,P.Dr 100,0000.T,U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE BCH.
MECHANICAL
p
l0
(We) agree to save, indemnify and keep harmless the City of
MISC. - REFER TO ORD.
Cu - against liabilities, judgments, costs and expenses which
y in y way accrue against said City in consequence of the
PERMIT ISSUANC ' 10.00 0.00
CONST. TAX
ranting this permit. '.
are of p wen ntractor Date
MECH. CO - LIC. N
MECH.
TOTAL /1,001
U 00
TOTAL
OFFICE COPY