15017 (4) Iv Ii-L. IN uvrulilvi/; I Il_,IV Sill IHiIv HED LINES - USE BALL POIIVT GEN ONLY
BUILDING PROJECT I DENT[FICATION PERMIT NUMBER "
8WIL.'ss 2!J' 'o I:Aitvd'ow APPLICATION & PERMIT
ADDRBUILDING -ELECTRICAL-PLUMBING -MECHANICAL ,.. 15017
OWNEII'S
NAME PLAN CHECK VALIDATION
Awn -I n� q// OTY• ELECTRIC PERMIT FEE
yt.0 LJ ry CU N Ar PHONE /[a`�7
CONTRAC OnS J Ol J A
NA�M,E, a., 66 OUTLETS-SWITCHES-RECEP 10,00/1.00
/,6ir- BnOk.YL lj uc.No
Z 2Z_ LIGHTING FIXTURES 10.00/1.00
ADDRESS IRAC�FS.Z.lr1 �'!
/r / ,j PPLIANCES-RESIDENTIAL 4.00
- *0,4 nvk- `~;v PHONL PANELS 10.00 GATE OF APPLICATION "
ARCHITECT
on PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0.
ENGINEER
l LIC.NO.C-166 S SIGNS TRANS. 3.00
ARCH. ENG.
ADDRESS SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP 'I EMP.METER OR POLE INS. 20.00
APPLICANT'S '�-^p{ ^
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 • �� ���
o¢ z
-02 LICENSI'IJ CON"f RACTORS DECLARATION
a v w I hereby affirm (hal I mn IicenSud under Provisions u1 Chapter 9
y a H (commencing will,Sell.On 7000)of Division 3 of tiro tlusiness and ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
r y z License Gla Cod and my lin'nse Is in full luqq a�nd�.•j'11-�'}�
o i wa License Clan_ _ Lic.Number X� ,2(.5 sz
w I_ D'em ��_ .? Con l me for
Q y E J O��
¢ ¢ w OWNIi R-BUILDER DECLARATION S BUILDING PERMIT
0
ILA
MISC.- REFER TO ORD INFORMATION
,u ' I- I hereby
allinn Ilett I all) •
W 3 Y I I uempl from Ille Contractor's License
r ..oj Law forth cry orconywhih e,7031.5,requiresa tloul Ileausilufessiur, VALUATION $/FT.
Ewi Code:Any city or county which requiresa pennitmconstrucLalreq PERMIT ISSUANCE 10.00 a- „�
¢ ¢ ¢ 0 improve,demolish,or repair any structure,prior lu its issuame,alw ELEC.CONTR. LIC.N0. J^ /,FO/ 60 0
ar o¢ requites file applicant lar such permit to file a signed stWnnonl Iha ELEC. &0
u w m he is licensed punrraal la thu provisions of the COntra,un's License TOTAL (+ PE}RxMIT TO
rzQLaw(Chapter 9(cununenciogwilh Section 7000)of Uivisio,3 of the - �l�U(.�L "
i o
Business and Profession Code)Or that lie 6 CFCmIt((herebroul and OTY. PLUMBING PERMIT FEE
SE the basis Ibr the alleged exelnpfion.Any violation of Section 703 LS STORIES TYPE CONSTR.
e. 3`�2 by any applicant for a Penal subjects the aPplicmn(na Civil penally
of not more(Iran five hundred dollars lS500).): ALTER-DRAIN& VENT-WATER (EA.) 5.00 � �
❑ 1,as owner at tire puperty,or my employees will,wages as BACK FLOW PROTECT
their Sole compensx(ion,will do the work,and tire . DEVICE 4,00e s(nlcfure is not O......UP RES.UNITS
intended ar uflered for sale(Sec. 7044, Business and Prul'essions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 o
Code:The Conrruclor's License Law does not apply to an owner of /`_. S
• Properly who builds ur improves thereon,and who.ucx such work Yr FIXTURES-PER TRAP 5.00
hinscll ar through his own nmpluyces.Provided that such ilnprove-
50.FT.FLOOR AREA TOTAL ACREAGE
menlsAre nountended or offered tarsale.l l',luwcver,file building GA$-EA.SVSTEM-11NC.40UTLETS 6.00 �
or impowculin( is sold wllhin one Year or cumplutiou, the owner �
builder will Ill"the burden of pruving Owl ha did nnl build or int. GAS-EA.SYSTEM-OVER 4 (EA.) 2 GOI L DING USE
prove for purpose alSu1e.t. RES IND CON PB Omer
❑ I,as owner 01 file property,as exclusively chaincho,with INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
licensed contraeto" 1. construct fire Prajocl(Sec. 7044,Business LAWN SPRINKLERS 1 INC 5 VB600 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law d - . . .
class not apply / /
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 3 U p- 0:3l
contracts for such projects with a cU bracior(s)licensed pursuant to T
the Contractors License Law. SEWER-SANITARY-STORMEA.200ft/10.00TRACTNO. PARCEL NO.
❑ 1 am exempt under Sec. ,li.&1'.C.('or this
reason WATER HEATER W/VENT 6.00
Owner Ume WATER SYSTEM 5.00
ACC.GATE ACC.FILE NO,
WORK RS'C'OMPISNSnTIUN OIiCI-A RA'RON WATER TREATING EQUIP. 5.00
1 hereby alfirm that I have a cerliltcale of consent to sell insure,
or o certificate of 1VarkeN'Cot s Iia Insnrunce,or a acnified ZONING ENG.SITE NO.
ropy 111 real(Sec.3800,I.ab.C.). �xs w
Policy No. Comp al y��IF"p•$; �LL_7 -c0 ,c
O ❑ Cerlilied copy is hereby furnished.
z Z ❑ Certified Cany is filed with the city inspection division. FIRE SPRINK ENERGY T-24
Applicant `_J'"•_1;4o y - MISC.- REFER TO ORD. 0 Y � N� Y ❑ ND
� N CERTI F-ICATE OP IiXC:MPTION FROM WOR K(IRS' PERMIT ISSUANCE FLOOD ZONE a.L.u.c.
LU > COMPENSATION INSURANCE NLG.CONTR. LIC.NO. PLG.
D' O (This section need our be completed if the permil is lar one TOTAL Yx �O Y N Y 0 ryo
Z hundred dallars(S100)or less.)
U Q 1 certify that to fire Performance of the work fur which this per- QTY. MECHANICAL PERMIT' FEE FEE SUMMARY
L_ U mit is issued,1 stall 1101 employ any Person in any manner un as In
OW become subject to the Workers'Compensation Laws of California. �� QO
G. Dat` ApPl1,.4n1 ALTER OR ADD TO MECH. 5,00 BUILDING -
} N NOTICI7 TO APPLICANT: II',offer making this Cerlilicme of lix-
F- 2 e...I'li., you should become subject to file Workers'Compeasalinn APPLIANCE 5.00 CHECK
PLAN
provisions of the Labor Code, you must farthwitb comply with
U such provisions or this Permit shalt be decried revoked. AIR HANDLING UNIT(TO 100(10C.F.Ni) 4.00 FEE
CONSMUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 6.00 SEISMIC FEE Fa C)
I hereby affirm that there is a construction lending agency far I EXHAUST HOOD WITH DUCT) 5.00
the performance of the work I'or which this permit is issued(See. I HEATING UNIT ITO 100,000B.T,U.) 8.00 MICROFILM
Lender's Name p
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.5 ELECTRIC eI=_
I certify(hot l have rend Misapplication and stale [all the all.V. 3 VENTILATION FAN (SINGLE) 4,0
information is correct. I agree to comply with all city and county PLUMBING / ll
ordinances and store laws whiling to building construction, and BOILER-COMP 13 H.P.or 100,000B.T.U.) 6.00 CO
hereby aulhoriu representatives of this city to enter upon the 0
above-mentioned properly for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL _
(We) agree to Save, indmmlify and keep harmless the City of MISC.- REFER TO ORD. /
uperlino against liubilities,judgments, costs and expenses which CONST.TAX 9/
may in any way accrue against said C'ily in consequence o1 (he• PERMIT ISSUANCE 1 a
•r:nlling of this penult" MECH.CONT. LIC.NO. MECH.
t3�r _ TOTAL (/� TOTAL n
A
signature oil raclur Uulc
/\ OFFICE COPY /•