18785 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT PERMIT NUMBER
AD
ADILDING
DRESS 18785
DRESS
BUILDING —ELECTRICAL—PLUMBING—MECHANICAL '-'
OWs, - PLAN CHECK VALIDATION
fANE QTY. ELECTRIC PERMIT FEE
PHONE
10
conrRACTOR's OUTLETS-SWITCHES-RECEP ]jL60{1100
vmaA
in&C NCk
LIGHTING FIXTURES 10.00/1.00
CONTRACTORS 1(11 (� _ APPLIANCES-RESIDENTIAL 4.00
EI 7
PHONE (J
A SS PANELS
310.00 DATE OF APPLICATION
I PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
on
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS eec. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS
APPLICANTS
ADDRESS MOTORS kEE F
SERVICE C NGE 20. 0
o o LIC17NSF1)CONTRACTORS DECLARATION
G v U I hereby affirm that I mm licensed under provisions of Chapter 9 ISSUANCE DATE "
H rt w (commencing with Section 7000)n(Division 3 of the BusinesOd It BLDG. ELECT. PLG. MECH.
w- m z I'ro(essions Cod , ns' se.is n'lull If
z O v, — Liccnm as Lie..Numb
0 H Dutc — Contruaor +
a Y s (�(-T BUILDING PERMIT
¢ ¢ m ¢ OWNIiR-tlUILUBR D[ChA INFORMATION
Ono MAC.— EFER TO ORD
F
u-y I hereby affirm that 1 am exempt from the Contractor's License
n O a Law for the following reason.(Sec.7031.5,Businessmd Professions pE IT S CE 10.00 VALUATION
— Code:Any city or county which requimsu permit lo,
onstruct,almq
IF w s-0 Improve,demolish,or repair any structure,prior t0 IIS ISSIIa11C0.aI50 ELEC.CON i. ELEC.
D u requires the applicant for such permit to tile a signed statement that TOTAL PERMIT TO
a w m w lie is licensed pursuant to the provisions of t e Contractor's License
h, zs- Low(Chapter 9(commencing with Section 7000)ofl)ivision3 ofthe
I E o Business unit Professions CoJel or that hu is exempt therefrom and QTY. PLU I G PERMIT FEE
¢ F the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a3 - by any applicant fora permit subjects the applicant toacivilpenalty ALTER-DRAIN& VENT-WATER (EA.)
of not more than five lmadmd dollars(8500).):
D I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sole (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND.
Code:The Contractors License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP >109SQ FT.FLOOR AREA TOTAL ACREAGE
himselfor through his own employees,provided that such improve-
menis are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 1 NC.4 0UTLETS
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 IEA.1 BUILDING USE
builder will have the burden of proving that he did not build or im-
Proveforpurposeofsale.l. INDUSTRIAL WASTE INTER. RES IND CON PB Ome,
❑ 1,as owner of the property,am cxolnsivcly contracting with ❑ ❑ - ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. vQ6 ASSESSOHS PARCEL NO.
and ProfessionsCode: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,)
contracts for such projects with a contractors)licensed purntant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200W1tQQ TRACT NO. PARCEL NO.
❑ I mo exempt under Sec.—,IL&P.C.for this WATER HEATER W/VENT
reason
Owner Dote WATER SYSTEM >< ACC.DATE ACC.FILE NO,
WORKF-RS'COMPENSATION DECLARATION WATER TREATING EQUIP. slAe
I hereby affirm that I have a certificate ofconsent to self-insure. ZONING ENG.SITE NO.
or a certificutu of Workers'Com hsatinn Insumncj-r� tifieJ
copyYhyegY($g},313f1,Lany-
folic N pany-
0
LJ.,I14V.)
O Cy CcrD ed copy is hereby l nnnsh ell. FIRE SgRINK ENERGY T$4
Z Z `d Cl bG y,pp,�is Ali w'' �I,y nspeUion division.
p APpllro ]h_y l— .lr(1-l�T MISC.- REFER.TO ORD. Y ❑ N❑ Y ❑ IN[J
CC rn CFR'I'l Iq CA'IE _131]EXEMPTION FROM WORKERS' PERMIT ISSUANCE 0 FLOODZONE A.L.U.C.
COM1IPF-NSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL Q (This section need nut be completed it the Permit is for ane TOTAL Y❑ N❑ Y ❑ N❑
:D 2 hundred dollars($100)or less.)
U O 1 certify that lin the performance of the work far which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of Calilcrnia.
O w Dale. Applicant ALTER OR ADD TO MECH. BUILDING
} y NOTICE TO APPLICANT: If.after making this Certificate of 11x-
F 2 mmption,YOU should become subject to the Workers'Compensation APPLIANCE PLAN CHECK
provisions of the Labor Code. you must forthwith comply will FEE
C7 Such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000 C.F.M) 0
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IQOOQC.F.m SEISMIC FEE
I hereby affirm that there is a cunstrunion lending agency for EXHAUST HOOD(WITH DUCT)
the pert'ormmhce of the work for which this pencil is issued(Sec. MICROFILM
3097.CI,.C.). HEATING UNIT(TO 100,000 B.T.U.) Iku
Lender's'Name H EATING UN IT(OVER 100,000 B.T.ULW ELECTRIC
Lender's Add .,S
1 certify that I have read this application and o.te that the above VENTILATION FAN (SINGLE)
information is correct.I agree to comply with all city and countyPLUMBING
ordinances and state laws relating m building construction, and BOILER-COMP(3H.P.or 100,000B.T.U.)
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL ^1
above-mentioned property for inspection purposes ` L
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TORD.
over tino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE i CONST.TAX
ay 'n any way accrue against said City in consequence of the
•an i • this perm MECH.CONT.N LIQ NO. MECH.
TOTAL TOTAL w
'g t eo ApplicantContrcDate. ss o + L
OFFICE COPY