7078 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
. ' BU I LDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING
H
APv^'PLICATIO2N'S& PERMITX '
ADDHESS Cr' BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
7078
S PLAN CHECK VALIDATION
$ELECTRICPERMIT kNaME/�
''.k^:;;. FEE• ,
/C PHONE
CONTRACTORS
NAMF
A ^ UTLETS-SWITCHES-RECEP 5.00/1.00
V~# /7EtlTlilJC LIC.NO LIGHTING FIXTURES 5.00/1.00
ADDRESS
crORsM T APPLIANCES+RESIDENTIAL 4.00
LmsePHONE 9- a PANELS - 5.00 DATE OF APPLICATION
aPCHrtFCTSIGNS 6.00 PLAN CHECK FEE P.C.NO.
OP
ENGINEER
" Sac.NO. ISIGNSTRANS. 3.00 ,
ARCH,OR ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
SS
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
w o o LICENSED CONTRACTORS DECLARATION _
a mU, I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
as c w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG.
H m z PnsEssinns Cole, pd yEy bene is in full force y ffxt, ❑ ❑ ❑
o i m W License Cl x:( Lie.Number VSr
,a Date - - Contractor ;P 9.
a m 5 a OWNER-BUILDER R-BUILDER DECLARATION - BUILD_-IING PERMIT
a¢o d U INFORMATION
I hereby affirm that 1 am exempt from the Contractors License MISC.- REFER TO ORD
u 0 a Law for the following reason.(Sec.7031.5,Rusinessand ProfessionsVALUATION S/FT.
� - Code:Any city m Bounty which requiresa permit mer nstruct,alter, PERMIT ISSUANCE 6,00
a ¢Q improve,demolish,or repair any structure,prim to its Pommoc,also ELEC.CONT". LIC.NO. ELEC.
-D, requires the applicant for such permit to file a signed statement that TOTAL '
atm a he is licensed Poisoner to the provisions of the Contractor's License PERMIT TO
F i
Law(Chapter 9(commencing with Section 7000)of Division 3 of the b1. �L� ''
F i o Business and Professions Code)or that he rs exempl therefrom and QTY 'laA,° yxP.CUMBING,re(�ERMITygklq, FE
H m the basis far the alleged exemption Any violatmn of5ection 7031.5 ,. - ,Y £ y'.., 1'L},',.- 'TT $ Y STORIES TYPE CONSTR.
(L ; _ by any applicant fora permit subjects the applicant ma'civilpenalty ALTER-DRAIN&VENT-WATER (EA.) q,00
of not more than five hundred dollars($500).): '
❑ 1,us owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP HES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for In(See .7044, Business and Professions DRAINS-FLOOR;ROOF,AR EA,CON D. 4.00 '
Code:The Contractor's License Law-docs not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4,00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.Provided that such improve-
mentsare not intended oroffered for Sale.If,however,the building GAS-EA.SYSTEM-l1NC.4OUTLETS 4.00
or improvement is sold within one year of completion,lite owner- GAS EASYSTEM-OVER 4 (EA) 1.00 BUILDING USE
builder will have the burden of proving that be did not build or im- - . .
REB IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
CII,as..net of the properly,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct tireproject(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code'The Contractor's License Law does not apply
to an owner o1pmperty who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
me Cont for such Projects Lwith u cnntramorls)licensee pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the Cont moor's License Law.
❑ 1 um exempt under Sec. ,BAP.C.for this
WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affmci that I have a certificate ofconsent to self-insure. - ZONING ENG.SITE NO.
or a certificat,of Workers'Compemsntiou Insurance,or a certified
copy there ofj l$$�cyy�.3jj1100,Luh.C.).
Policy Nr.(�!L(GXmpany_�_T PQ/sE -
0 ❑ �Uified ¢hereby f hed - FIRE SPRINK ENERGY T 24
Z Z LY�Certified o fled I c'ly i smechant division.
MISC. REFER TO ORD.
O Applicant_ c � V❑ N❑ V ❑ N❑
~ w+ PERMIT ISSUANCE 6.00
'� - fliRl'IItlCCOI PE SXER)N'INSUR(IM WORK ERS' FLOOD ZONE a.L.U.C.
W � COMPIiNSAI'ION INSURANCE PLG.cONTR. LIC.No. _ PLG.
C 0 (This section need not he completed If the lmort is for one TOTAL Y❑ N❑ Y❑ N❑
D Z. hundred dollars IS 100)or Icsv.) I I
0 O I certify that in the performance of the work for which this per- QTY. .. MECHANICAL PERMIT .'.FEEISUMM'A'R�V
LL I- and is issued,I shall not employ any person in any manner so as to „
0 L) become subject to the Workers'Compensation Laws of California. BUILDING
a Dute Applicant ALTER OR ADD TO MECH400
} m NOTICE TO APPLICANT: If,after making this Certificate of Ex-
. .
? ehoption,you should became Subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of Lite Labor Code, you must forthwith comply with FEE
U such previsions or this permit shall be deemed revoked. _ AIR HANDLING UNIT(TO 10=CF.M.) 3.00
CONS'T'RUCTION LENDING AGENCY - AIR HANDLING UNIT(OVER 10DWC.EM.) 5.00 SEISMIC FEE
„ 1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of lite work 1'nr which this permit is issued(Sec MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lenders Name -
Lender's Address HEATING UNIT(OVER 100,000B.T.U.)7.50 ELECTRIC
'
I certify that 1 have iead'this application and stute.thut the above VENTILATION FAN (SINGLE) 3.00
` inl'ormulion is correct.I agree to comply with all city and county PLUMBING
ordinances and state laws relating m building construction, and BOILER-COh4P�3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000BTU)SEE FEE SCH. MECHANICAL GO
above mentioned property for inspection purposes. - s
(We) agree to save, indemnify and keep harnless Ilia City of 'MISC.- REFER TO ORD.
Cup tion against liabilities,judgments, casts and expenses which PERMIT ISSUANCE- 3.00 CONST.TAX
any way are a against mid City in consequence of the.
gr' sting it peso MECH.CONT. LIC.NO. MECH.
. / E t 1 TOTAL TOTAL Od
Signature o ApPi CamJContras r Uule /1' GrTT NG =, ��
OF ICE OPV`