18661 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 18661�[� i
ROD4ESO^ - �. I v 6 I
e BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
"AME OTY. ELECTRIC PERMIT FEE
O I PHONE (J�J�� I�
�`-•, CONTRACTORS
ACTORS UTLETS-SWITCHES-RECED 10.00/1.00
C Q ILID.NO. LIGHTING FIXTURES 10.00/1.00 P A ' U
CONTRACTORS
AonnEss p`� ,flu{, PIA PPLIANCES-RESIDENTIAL 4.00
PHOrvE �V��l PANELS 10.00 TEO AP ION
ARCHITECT EC E .C. O.
on PANELS LOVER 200 AMP) 20.00
ENGINEER
LIC.NO. SIGNS TRANS. 3.00 ;IT}'
AAD(mFSss ErvG' SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
VP TEMP.METER OR POLE INS. 20.00
ASMOTORS SEE FEE SCR.
ADDREDDRESSS
SERVICE CHANGE 20.00
o¢ i
Foo hI('IiNS1iU CON I'NACTORS I1 f;('LARATIONTfq
a Z W I hereby arrinn that I am licensed wWer provisions of Chapter 9 ISSUANCE DATE
l commencing whir Section 7000)of Divisiou 3 of file Business and
Io a H COMPUTEFBLDG. ELECT. PLG. MECH.
F D Z Professions cMf.an m Incase is in full forisLlgl effect. ❑ ❑ ❑
o Z vvl a Licehse�ass�y" _ Lic.Number/�''LL'�T .r�
F y H J Uafn- �`_ LL-�� _('ontrn[lor_yLL_ 1_' �1L1Q {/ if
a >< _ , 1�y DATE / /• �' BUILDING PERMIT
tea OWNER-BUILDER DECLARATION
c w v INFORMATION
X 3,c 1- I hereby nfftnm that I am exempt from the Cnntraclur's License MIS .- REFER TO ORD
a VALUATION S/FT.
F u m J Law for the fallowing rcuaR(Sec.7031 5,0usiness and Professions PERMIT ISSUANCE 10.00
E W 0 county Code:Any city or coy whichmgniresapenm
ritionslru
Z ch miler,
a O improve.demolish,or repair any structure,prior In its issuumce,also ELEC.CONTR. LIC.NO. ELEC.
a Wm M requires(lie applicant for each perm it to file B signed statement that TOTAL PERMIT TO
m he is licensed pursuant to the provisions of the Contractor's LicenseFZ > Law(Chapter 9(commencing with Section 7000)of Division 3 of(he
a Business and Professions Code)or that he is exempt 0haefrons and OTY. PLUMBING PERMIT FEE
M 1=- the basis for the alleged exemption.Any violation of Seelion 7031.5 STORIES TYPE CONSTR.
V by any applicant for a Permit subjects the applicant to a civil penally ALTER-DRAIN -WATER IEA.) 5.OD
of not more than five hundred dollars 155001.1:
❑ I,as owner of the Properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their Sale compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or holuoves thereon,and who docs such work F IXTUR ES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
ments are not intended or offered for sale.IL however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is will willun one year of cumplelion,file owacr- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have Ilse burden of proving that Ile did not build or I,,,of sale
prove for pRES IND CON PB Other
urpose .). INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ El 1:1 1:1❑ 1,as owner of the pmpetly,am exclusively contracting with
licensed contractors to construct the project ISec. 7044•Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PAROELNO.
and Professions Code:'I lie Contractor's License Law does not apply
to as owner of properly who builds or immroves thereon,and who LAWN SPRINKLERS-OVER 51EA.) 1.00
con Uacts for such Projects with a cmdractov s)licensed pursuant to
the Cmometors License Law. SEWER-SANITARY-STORM EA.2001t/10.00 TRACT NO, PARCEL NO.
❑ 1 ens exempt under Sec.-,Il.&P.0.far this WATER HEATER W/VENT 6.00
reason
Owndr Dale WATER SYSTEM 5.00
ACC.OATS ACC,FILE N0.
WORK 1:RS'CONPI!NSA'1'ION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that I have a certificate of conte ill In self-tnmm. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a yell iIt,d
Copy thereof) c 1 00 Lab.C.I
Policy NolL1 R-1 'rf�liltamY-Sul I��I-AI.IIYIL
O ❑ Certilied copy is hereby fumislue FIRE SPRINK ENERGY TQ<
Z Z Crrli ampy is 01 it it Ifs. city inspection division.
H' O Applicxm _fs.f_ -�L MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
CCN CFRTIFICATE OF EXRMPPI ION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W COM PIiNSATION INSURANCE. PLG.CONTH. LIC.NO. PLG.
CL O (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N
UO Zhundred dollars CS 100)or less.)
I certify that tm the performance of the work for which this per FEE SUMMARY
IL F aril is Issued,I shall not employ may person in may moo...xn as In DTV. MECHANICAL PERMIT FEE
O O lrecone subject to lhv Wnrkcrs'Canmensulimn laws of Calicoda.
Doc Applicant BUILDING
} ALTER OR ADD TO MECH. 5,00
85 NOT R.17 10 APPLICANT If,after ranking this('ertilicate it rix
I- Z "N'liun,you should become IrblCCl to the Workers'Cnnrpcnsallan APPLIANCE 5.00 PLAN CHECK
pravisons of the Iahor Colic, you must lorlhwith c nrply with FEE
U such nmvisions of this permit shall he dee ned revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONST'RUCI'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10J.1000.F.M.) 6.00 SEISMIC FEE
I hereby aflirn that there is a construction Irndiae agency for EXHAUST HOOD (WITH DUCT) 5.00
the ferfannance of the work fill which this permit is issued(Sec. MICROFILM
3097.Civ.C.), IHEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Leruler's Address HEATING UNIT(OV ER 100,000 B.T.U.)8.50 ELECTRIC
IceNily that l have read llds applicalina and slate)hal the above VENTILATION FAN (SINGLE) 4.00
• information is correct. 1 agree to Comply with all city and county PLUMBING
� ordinances and state 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 IOym 100,000 BTU)SEE FEE SCH. MECHANICAL -I!0_
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD lyi
uPeOlno against liabilities,Judgments, costs and expenses which I PERMIT ISSUANCE 10.00 CONST.TAX
may in any way Beenne against said City In consequence of the
len ofAhisper iI. MECH.CONT. LIC.NO. MECH.
�Y �G O'G• t `� /o •S 9 �(n yfL'L rOT� TOTAL
Signature of Applicant/CD cloy Dale
OFFICE COPY