6142 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATION PERMITNUMBER
BBmLDIry APPLICATION & PERMIT
ey.,ADDness '• UILDING - ELECTRICAL-PLUMBING-MECHANICAL 6142'
Z
PLAN CHECK VALIDATION
OTY. ELECTRIC PERMIT FEE
' C
PHONE �/ � i
CONTRACTOR'S UTLETS-SWITCHES-RECEP ,5.00/1.00 '
NAME
' 4 .uc.No, LIGHTING FIXTURES . .'5.0011.00, -
CONTRACTORS
AO SR PPLIANCES-RESIDENTIAL 4.00
1 NE PANELS. :S.00 DATE OF APPLICATION
A Cm TECT ' PLAN CHECK FEE P.C.NO.
OR SIGNS 6.00
ENGINEER
LIC.NO, SIGNS TRANS. . 3.00
ADDRESS ENG
SPECIAL CIRCUIT - •5,00 PERMIT VALIDATION
t ZIP TEMP.METER OR POLE INS. 15.00 J
APPLICANTS MOTORS - SEE FEE SCH: - (�
ADDRESS _J
SERVICE CHANGE 10.00 G '
0. 2
LICENSED CON'rRACIORS DECLARATION IPAIn /0
Q v U
'I hereby afrnn that I uns licensed under provisions io'Clmpter 9 ISSUANCE DATE l
w i w (commencing with Section 7000)of Division 3 of the[business mal OCT 2
_ BLDG. ELL�ECT. PLG. MECH.
F A z Professions Code,and my license is in full f tnee:md effect ❑ LECl '❑ ❑
p 0,n Licensc Clan Lia Nmnbcr
Q y L J DaIL' Contact.,. � ' /s+
Ix S,w a OWNF:R-RUI I.Uf. IJIiCLARnI'ION City Of Cu BUILDING PERMIT
I MISC.:= REFER TO ORD INFORMATION
N I hereby affirm that I am exempt from the Contractor's Licensc
FLLOG Law for the following came.(Sec.7031.5,Businessend PRsfessions PERMIT ISSUANCE ' 6.00 'VALUATION $/FT.
Code:Any city or county which requires a permit to construct,alter, -
� ao improve,demolish,oreepairanystructure,prior to its issuance,alsn ELEC.CONTR. 'LIC.NO. ELEC.
O IF requires the applicant I.,such permit to file a signed statement that TOTAL r
n w Cs hes.license
id pursuant to the provisions of tire ContractorPERMITTO
Contractor's License' -
Fzi w
Ia (Chapter 9(Commeneiagwith Section 70001of Division 3 ofthe :'T�F^�1..I�.1 Owd•Y_
f a: o 'Buslness'and Professions Code)or that he is exempt oaretimn and CITY. PLUMBING PERMIT FEE /
1L I-m the basis for the alleged exemption.Any violation of Section703L5 - STORIES TYPE CONSTR,
by any applicant for a permit subjects the applicant boa civil penalty ALTER-DRAIN (EA.) ° s
of not mon,than five hundred dollars($500).): - -
❑ 'I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 2.00 " OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not -
iotended or offered for sale (Sec. 7044, Business and.Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code:'f he Contractor's License Law does not apply to an owner.['
5� property who builds or Improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himselfor through his own employees,provided that such improve.
meats are not intended or offered for sale.If however,the building GAS-EA.SYSTEM+1 INC.4 OUTLETS 4.00
improvement is 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 not build or im-
prove for purpose ofsale.). L INDUSTRIAL WASTE INTER. RES IND CON PB' Other
❑ I,as owner of the property,Sri exclusively emamcling with 20.00 ❑ ❑ ❑ ❑ ❑
licensed contractor, to Construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. , 5.00 ASSESSORS PARCEL NO.
and Professions Code:'I'he Contractor's License Law does not apply
to air owner of property who builds or improves thereon,and who LAWN SPRINKLERS:OVER 5(EA.) 1.00
contracts for such projects with is eontractods)licensed pursuant to
the Contract.,',License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ Iron exempt under Sec. ,B.&Poco fnrtl'is WATER HEATER W/VENT 4.00 - '
a,fl
It, WATER SYSTEM 4.00
ACC.DATE Acc:FILE No.
WORK ERS'COMPI: SAI 10 DECLARATION - WATER TREATING EQUIP. 4.00
I hereby affirm that I have is certificate of consent to sell'-insure,
or Is Certificate of Workers'Campers ation Insurance,or a certified ZONING . ENG.SITE N0.
,o,Iher'of(Sce.3800,Lnh.C.). -
Policy N.. Company -
O ❑ Certified copy is hereby furnished. FIRESPRINK ENERGY T 24
Z z O Certified copy is filed with the city inspection division. MISC.- REFER TO ORO.
O Applicant Y ❑.- Is C-] Y ❑ N❑
a:,ti CERTIPICA'lE 017 EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
W > - COMPENSATION INSURANCE PLG.CONTR, LIC.NO, _ PLG.
(This section aced not he completed if the pannit is Is .
I. nN
e '- TOTAL t Y❑ 'N❑ t Y❑
Z ❑
hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued,I shot] nor employ any person In ally steamier r,0 as to
• Ow f become subject to the Workers Compensation Laws oCalifornia. _ - -
n - Date Applicant ALTER OR'ADD TO MECH.' 4.00 BUILDING -
} rD 'Nf NCE 10 APPLICANT'. If,after making flus Certificate of Ex-
Z emption,you should become subject to the Workers'ConlpensatGR APPLIANCE '- - 4.00 PLAN CHECK
provisions of the Labor Code, you must I'..thwith comply With FEE'
U, Sault provisions or this permit shall he deemed revoked.• AIR HANDLING UNIT ITO 10,000C.F.M.) 3.00
CONSTRUCTION LENDING ACHNCY. AIR HANDLING UNIT(OVER 10MC.EM.) 5.00 SEISMIC FEE
'I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT[ 2.00
OR, performance of the work for which this permit is issued(Sec. MICROFILM'
3097,Civ.C.).' HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(DV ER 100,000 B.T.U.410 CZ
,-
I
Address ELECTRIC CZ,-
' I certify that l have read this application and state'thdt the above VENTILATION FAN (SINGLE) 3.00
t information is correct.I agree to comply with ahbeity and.county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby autho}iee representatives of this city-[o enter open the
above mentioned property for inspection purposes. BOILER-COMP(Over 100,000 BTU)SEE FEE SCR. MECHANICAL.
(We) agree oto save, indemnify and keep harmless the City of MISC.- REFER TO ORD. - -
CufacRim ' st liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
Go any w 'ecru, against City in consequence of the '
noting of❑lisp nnit. CH.CONT. .LIC NO. MECH.
TOTAL TOTAL
Signatu •of'Applicmlt/Cont' Uate
OFFICECOPY