13368 (4) -APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 13368
ADDRESS
BUILDING — ELECTRICAL—PLUMBING—MECHANICAL
OVINE 'S I PLAN CHECK VALIDATION
NAME
R'1 OTY. ELECTRIC PERMIT FEE
r,� PHONE
NONTRACTORS ''11 (r AME �UTLETS-SWITCHES-RECEP 10.00/1.00
C•LIN tEYI LIC.NO.4r��231102- LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00
ADDRESS yL
5 "`�•. PHONE 1PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS(OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO, SIGNS TRANS. 3.00
ARCH,OR END. SPECIAL CIRCUIT S.QQ PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 20.00 n
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 .71,),-
o o LICENSED CONTRACTORS DECLARA'I ION //
a.U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
h<y (Commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H G z Professions Code as d my license is in full force and af'ect. ❑ ❑ ❑
Z D-'/� License Class Lic.Number
0 m H w Use, Contract.,_41yt
1– m sBUILDING PERMIT
¢ ¢ic ¢ OWNF-R-BUILDER DECLARATION INFORMATION
o a D MISC.— REFER TO ORD
w 3 u w 1 hereby affirm that I am exempt from the Conlmetor's License
o¢ Law for the following reason.(See.703 1.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
FLL0 Code:Any city or county which requires a permit to constmcl,alter,
La ¢ improve,demolish,of repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
o a a D a requires the applicant for such permit to file a signed statement that TOTAL PER MIT TO
Is$ he is licensed pursuant tothe provisions of the Contractor's License �A
H 2 i Law(Chapter 9(commencing with Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
sio
¢ $ thebasisfor the alleged exemption.Any violation of Section 7031.5 I STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5,00
of not more than five hundred dollars($500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
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 ins proves thereon,and who does such work FIXTURES-PER TRAP 5.00 SD.FT.FLOOR AREA TOTAL ACREAGE
• himselfmthrough his own employees,provided that such improve- GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
mems are
not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the ownerGAS-EASYSTEM-OVER 4 IEA) 200
builder will the burden of proving that he did not build or an.
. . . BUILDING USE
prove for purpose ofsthe p INDUSTRIAL WASTE INTER. 30,00 RES IND0 CON pB 0
ther
O d as owner of the property,am exclusively.7044,tBu with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct [he project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
to Professions Code:The honb uilds s License Law Joos not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1,00
contracts for such projects with a contrac(or(a)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.GATE ACC,FILE NO.
WORKF-RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent so self-insure, ZONING
or a Certificate of Workers'Compensation Insurance,or a certified ENG.SITE N0.
copy thereof(Sec.3800,Lab.C,I.
Policy No. Company en oft! T" al"
0 ❑ CertiOedc y is hereby furnish FIRESPRINK ENERGY T-24
5 Certif rs filed th the cit insp n division. MISC.- REFER TO ORD.
ZO I' Applicant (� k Y❑ N❑ Y ❑ N❑
CC CERI'IFICATF-01:EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU LU OCOMPENSWION INSURANCE PLG.CONTR. LIC.NO. TPLGb
OTAL V❑ N❑ V [:] N❑
(This section need not be completed if the permit is for one
Z lot rutted dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- MECHANICAL PERMIT FEE FEE SUMMARY
LL P mit is issued.I shall not employ any person in any manner so as to '
U become subject to she Workers'Compensution Lawsof California.
a Date ApplicantALTER OR ADD TO MEC 5.00 5.,C. BUILDING
ut
} N NOTICE TO APPLICANT: If,after making this CeNifice of Ex
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
Provisions of the Labor Code, you must forthwith comply withFEE
U such provisions or this permit shull be deemed revoked. AIR HANDLING UNIT ITO 10 CXM')' 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT( VER 1` C.F.M.),s 00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DU Tt)110C 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L + HEATING UNIT ITO 100,000%B.t.U.) 8.00
Lender's Name HEATING UNIT(0 VER 100,000 B.T31)9.50 ELECTRIC
Lender's Address
I certify that l have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00 &cIicni
In
is correct. I agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,o00BTU)SEE FEESCH. MECHANICAL --77 $
above-mentioned properly for inspection purposes. C'�V
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Capert no against liabd=a'jaiZ'jp'.ind'
' es, cos s and expenses which PERMIT ISSUANCE 10.00 to-o6 CONST-TAX
may i any way aceity I onsequence of the
granti of this permi MECH.CONT. LIC.NO. MECH. )
7—n— TOTAL 01 �i
gnalureo pp wan/ othaeor Date CLittAt -i- 4539oa- 3 TOTAL
OFFICE COPY