8322 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES.- USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION PERMIT NUMBER- APPLICATION & PERMIT
euILOINc A a.,x v
AOORE55 G
BUILDING-ELECTRICAL-PLUMBING-.MECHANICAL G
OWNER'a PLAN CHECK VALIDATION
NAE
PHDNE3 a� PT-Y.1 ELECTRIC PERMIT FEE
r . A�7 coo
NONTRACTOR's OIGUTLETSNG FIX-SWITCHES-RECEP 10.00/1.00
u C.N LHTITURES . 10.00/1.00
CONTRACTORS
A GESn APPLIANCES-RESIDENTIAL 4.00
4`'•Q aRory / PANELS10.00 DATE OFAPPLICATION
ARC ITECT - PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER - ,
uc.No SIGNS TRANS. 3.00
ARCHOR ADDRESS ENG. - SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 'l
APPLICANT - MOTORS SEE FEE SCH. !�'�V•/
aoDREss
0 o LICENSED SERVICE CHANGE - 20.00 2
o i TEMP.POLE 30,00 LICENSED CONTRACTORS DECLARATION
a v La I hereby affirm find I am licensed under pmviswas of Chapter 9
H z to ISSUANCE DATE
a d (commencing with Section 7000)of Division 3 of the Business and'
BLDC. ELECT. PLG. MECH.
F w Oz Professions C 'P'u y license ism full f �1 ❑ ❑ -
Zo zo too License C!ss Lia Numb
Uale Comraclor
a � w a
OWNER-BUIL DF.R DECLARATION BUILDING PERMIT
w- O e, " MISC.- REFER,TO ORD INFORMATION
;LL H I hereby affirm That I am exempt from the Contractor's License
.. o¢ Law.for the followingreason,(Sec.7031.5,liusinessand Professions VALUATION S/FT.
H - PERMIT ISSUANCE 10.00
am � Cuda Any molish um nlywhiny structureP rioitfownsuance,also
T ¢ improve, or repair any structure,prior to its issuance,also ELEC.CONTR. LIG NO. ELEC.
O LL requires the applicant for such permit to file a signed statement that TOTAL
PERMIT TO
a w$ < he is licensed pursuant en the provisions of the )of Contractor's License -
H i Law(Chapterand
Professions
Code)
or Section is exempt
DItterefoonon 3 the
i o Business and Professions Code)or that he is exempt tterefrnn and OTY. PLUMBING PERMIT FEE
W $ the basis for the alleged exemption.Any violation of$ection 7031.$ STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty - ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(8500).):
❑ 1,as owner the property,or my employees with wages as BACK F COW PROTECT.DEV ICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
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 improves thereon,and who does such work FIXTURES-PERT AID5 00 SO.FT.FLOOR AREA TOTAL ACREAGE
,• himself or through Isis own employees,provided that such improve-
mcnfsareotintendedorofferedlTor sale.If,however,the budding GAS'-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is oild within one year of completion,the owner
builder will have the burden of proving that he did not build or im- - GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
.prove for npau ol'sale.l. - , t. me
INDUSTRIAL WASTE INTER. 30.00 RES IND •CON PS Or
C3I,as owner of Ole property,ant exclusively Contracting with - ❑ 0 ❑
licensed contractors to construct the project(Sec. 7044,Rosiness LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
Slid Professions Code:The Contractor's Licetise Law does not apply -
to nn owner of property who builds or imptovesRieraon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 _
contracts for such projects with a eontractons)licensed pursuant 10
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I ant exempt under Sec. ,B.&P,C.lu,this WATER HEATER W/VENT 6.00 1
reason
Owner Date - WATER SYSTEM 5A0 ACC.DATE ACG FILE NO.
WORKERS'COMPENSA'1'ION UECLARA'f ION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconsenl to seif-insure,
or it certificate of Workers'Compensation Insurance,o"/certified ZONING ENG.SITE NO.
Q we
I'n�EL'L �:oiRltanY��-��-/�Ga�(1-
it copy is hereby ft rmshed. FIRE SPRINK ENERGY T"24
Z Z erNficd copy is fled with the city inspection division.
� O Ar t t MI SC
REFER TO ORD. YO.
PERMIT ISSUANCE
� N CF-RTIFICATF,OF EXEMPTION PROM WORKERS' -(,/ FLOOD ZONE A.L.U.C.
LL - COMP17NSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
C IThis section need dol be completed if fie permit is for one TOTAL 2 V NC1 -Y c N11
Z) Z hundred dollurs(SI00)orless.)
CJ O 1 certify that in the pertormovice of the work for which this per- OTY. MECHANICAL PERMIT FEE
LL H mil is issued,I shall not employ any person in any manner so as to FEE SUMMARY
U become subject to the Workers'Compensation Laws of California.' _
y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NO]ICE'f0 APPLICANT: If,afIcr making this Certificate of Ex.
? emption,you should become subject to the Workeri Compensation' APPLIANCE 5.00 PLAN CHECK
provisions of the labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked, AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(See , MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address - HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP 13 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives ec this city es enter upon; the BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
hereby
above-mentioned property forinsp of this
purposes.
(We) gree to save, indemnify and keep harmless the City of MISC.-' REFER TO ORD.
grantiig
ainst liabilities,judgments, costs and expenses which CONST.TAX
P
accrue against said City in consequ cc of the . PERMIT ISSUANCE ,10.00
MECH.CONT. LIC.NO. MECH.TOTAL TOTAL � (-,o
cant/ ontrac or It"Im'Date
OFFICE COPY