4898 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI_ POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON '" '"� PERMIT NUMBER .
aVILDING APPLICATION & PERMIT A O Q
AooR ss `
BUILDING =ELECTRICAL-PLUMBING-MECHANICA8 0
L
OWNER' - PLAN CHECK VALIDATION
\, 1 NAME g QTY, ELECTRIC PERMIT ,FEE
l� \ UICV� I=Rorvi•'
NAIVERACTORs ..ts^'�t�1UTLETS-SWITCHES-RECEP 5.00/1.00
LIC.No�{O �0� LIGHTING FIXTURES 5.00/1.00 pA'D-
foNT ACTORS C7 - qpp LIANCES-RESIDENTIAL 4.00
ACDR
S ..11
NUE PHONE qqn•-uGL PANELS 5.00 E F P(i�u(�kat
ARC TELT C
OR SIGNS - 6.00 P EC FEE P.C.NO.
J t
ENGINEER
Lie.NG. - SIGNSTRANS.- 3.00 - QC Ino
NIP'ARCH.OR ENG.. vAUDAnON
ADDRESS - SPECIAL CIRCUIT 5,00
ZIP EMP.METER OR POLE INS. 15:00
ADDRESS - MOTORS SEE FEE SCH. w
ADDRESS -
SERVICE CHANGE 10.00 ,\\\
0 0 0 LICENSED CONTRACTORS DECLARATION - ( w e-J I
Q'i w I hereby uffirm'lhut I am licensed under provisionsof Chapler9 .Q CE DATE
h (commencing with Section 7000)of Division 3 of the Business and
< ,dr R
Professions Co and m -
r w z y license is in full fELECT. PLG. MECH,
oGc�ur effect
2 o u,- License lass ,� Lic.Numher�E - .� ❑
2 z r �. Date Contract
< yC
� ( - Z3
¢ ¢ w OWNER-BUILDER DECLARATION R/ t =r BUILDING PERMIT, -
o A o f,INFORMATION'
E:
g N .I hereby ar tire ffirm that I am exempt from the Contractor's is License MISC.- REFER TO ORD
u VALUATION $/FT.
FLLo ¢ Lawf Any
or county
requires a permit
to
Professions PERMIT ISSUANCE 6.00
Code'.Any city or county which requires permiuo constmct,alter, - _ �.�5�
¢ m ELEC.CONTR. LIC.NO.
¢ a o bnprove,demolish,or repair any structure,prior m its issuance,also ELEC.
o¢ requires the applicant for such permit to file a signed statement that TOTAL
e w m w he is licensed pursuant to the provisions of the Contractor's License PERMIT TO -
'ar z a Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe - -
o Business and Professions Code)or that he is exempt therefrom:uul QTV,. PLUMBING PERMIT FEE. lC/
¢ I- m the basis for the alleged exemption.Any violation of Section - RIES TVP,I gONSTq,
i ; � by any applicant for apermit subjects the applicant ton civllpmalty enalty ALTER;DRAIN&VENT-WATER (EA.) 4.00 �A"'G�/•7
Of not more than five hundred dollars($500).):
❑ L as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intendedor offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The.Cmametor's License Law does not apply to an owner of
Property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 50.FT.FLOOR AREA TOTAL A REAGE
himself Or through his own employees.Provided that such improvm -
mentsarenotintendedoroffered for sale.If,however,the handing GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement ie,sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did nobbulld or in,
prove for purpose of sale.). r INDUSTRIAL WASTE INTER. E IND CON PS other
❑ I,as owner of the property,am exclusive) contracting 20.00 ❑ ❑ ❑ ❑
p p Y. e gwith '
licensed contractors to construct the project(Sea 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and.Professlons Code:The Contractors License Law does not apply .
to.un owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00 '
contracts for such projects with o contractork)licensed Pursuant to SEWER-SANITARY-STORM EA:200ft/6.00
the Contractor's License Law. TRACT NO. PARCELNO.
❑ 1 am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM - 4.00 ACC.DATE ACC,FILE NO.
WORKERS'COMPENSAT ION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to self-insure, '
or a cetlifeme of Workers'Compensation Insurance,Or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lah.C.).
Policy No, Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z'Z �jCertificd copy is fled with the city inspection division
O na e . MISC.- ❑ ❑N V ❑ ❑
_ REFER TO ORD. v -' N
va� PERMIT ISSUANCE 6.00- CERTIFICATE OPEXEMPT EXEMPTION WWORKERS' FLooD ZDNE A.L.u.c.
'W'2:' COMPENSATION'INSURANCE PLG.CCNTR. LIC.NO. = PLG. '
a'O (This section need not be completed If the permit is far one TOTAL - 'V❑ N❑ Y ❑ N❑
D Z hundred dollars($100)or less.) '.
'r U O I certify that in[he performance of re work for which this per- QTV. ' MECHANICAL PERMIT, - FEE .' --FEE SUMMARY r
W F- In"rs iss ed,I shall not employ any Paan ny m rm •r so as to - "
Q W becom}y.� a a t e Workers'C cos o 'fornix a - '
y DoT E P IICPP
AN I ALTER OR ADD TO MECH. 400 BUILDING
} N NOTIICCG P ICAN'f: If,after maki Itis CerDficate fix -
Z emptiau, au should become Sohject to 0 Workers Compensation APPLIANCE 4 00 PLAN CHECK
t provisions of the Labor Code, you must forthwithcbM.)7mly with --- FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,0001 3.00 -
CONSTRUCTION LENDINGAGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 5.00 SEISMIC FEE t
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of"tire work for which this permit is issued(See. MICROFILM
3097,Civ.C.). HEATING UNIT'ITO 100,000 B.T.U.) .4:00
Lender's Name HEATI NG UN IT E R 100,000 B.T.U.17.50
Le_ der's Address - ELECTRIC
I certify that I have read this application and state that the above - VENTILATION FAN.(SINGLE) 3.00 -
information is correct 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction:and BOILER-COMPI3H:P.or100,0006.T.U.) 4.00
hereby authorize representatives Of this city to enter upon the BOILER-COMP IOver 100,000 BTU)SEE FEE$CH. MECHANICAL
above-mentioned property for inspection purposes.
- ' (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupe"I'�-,'mmctor
' s,judgments, costs and expenses which - CONST.TAX
may gainst said Ctry in consequence of the PERMIT ISSUANCE- 3.00granlMECH-CONT. LIQ NO. MECH.
-7 111
oTALTOTAL.Signature of App] / oD
'.OFFICE COPY