18857 (4) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER .,
DILOINc, APPLICATION & PERMIT, - 5�7
O A 0 r1.
.
ADDRESS = ,
BUILDING -ELECTRICAL-PLUMBING=MECHANICAL ' . :�l( 8 v v
I
OWNER'a _ PLAN CHECK VALIDATION
NAME PLAN(( � _ OTY.. ELECTRIC PERMIT ,, FEE /t
_• J . L ONE ' f�. 1' 1
CON DIACTOR'5
NAIVE OUTLETS-SWITCHES'-RECEP 10.00/1.00 _ .4
7 LIC.NO. LIGHTING FIXTURES' 10.00/1.00
ADDRESS Ton's PPLIANCES-RESIDENTIAL 4.00 f�
PHONE PANELS '. 10.00 -I I''�DATE'IF gPP SCATION
ARCHITECTPLAN CHECK FEE Y.C.NO.
onR 40I 91:14--HI I YgzcTr PANELS (OVER 200 AMP,). -20.00
imrvE - - -
Lt✓ •• (o�VL (�uyc.Noy SIGNS TRANS. - � 3.00ARCH GhfOl j:fIJIQ►fj�(
ADDRESS ENG,2 l`�3 4'�"1 5/ . SPECIAL CIRCUIT 5.00 PERMIT VALIDATION .
SeC-A i'//O TEMP.METER OR POLE INS. 20.00 AIVJyt VGCr
' APPLICANT'S Air Mc.lr, - -
ADDRESS I' � MOTORS SEE FEE SCR.
E:
G 0 SERVICE CHANGE 20.00
o o LICENSEDCONTRACTORS DF.CLARA'HON - - -
ao 1 hereby affirm (ha( I am licensed under pmvlsioos of Chapter 9 - 'e f '!
a fern mm..eneing with Section 7000)of Division 3 of the Business and - ISSUANCE DATE -
G w i• Professions Code, 1 my9icense is in full force and eff,,L
BLDG. ELECT. PLG. MECH.
z O w - License CI s Lic.Number g7Ygo -
m F Date 13 2( Contractor 16 a _LSdLO '4•
Q Y 3
It ¢ w ¢;'- OWNER-BUILDER DIiCLARATION ,"BUILDING PERMIT
o a c) -'+ r - INFORMATION
t
• w g u I hereby affirm that 1 am exempt from file Cn d uclor's Licensc MISC.- - REFER TO ORD a.
Hnoa Luw lot the following reason.(Sec.7031.5,Busine,and ProfessionspERM1T'ISSUANCE - VALUATION $/FT.
Code:Any city orcotmty whichrequiresapermittisconslruct,alteq lO.OD ` fu�/�E
o, ¢ ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. •y[ .Ia
ce D ¢ requires the applicant for such permit to file a signed statement that TOTAL
w $ he is licensed pursuant to the provisions of the Contractor's.License - . -PERMIT TO
g,ii
Law(Chapter 9(commencing with Section 7000)of Division 3`ofthe f SLA HE-'0 Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT. FEE I/VI G-�1
.2-1. o - the basis for fire alleged exemption.Any violation it'Seclion 7031.5 STORIES TYPE CONSTR.
A ; m by any applicant for a permit subjeclsthe applicLnnoacivilpenalty ALTER-DRAIN -WATER IEA.) 5.00 -
of Dol more than five hundred dollars($500).):
❑- 1,as owner of the property,or my employees with.wages as .BACK FLOW PROTECT.DEVICE '4.00 DCC.GROUP REB.UNITS
their sole compensation,will do the work,and, the"structure is not
intended or offend lour sale(Sec. 7044, Business zine[Professions ` DRAINS-FLOOR,ROOF,AREA,COND. 5.00 521
Code:The Contractor •License Law do.not apply to an owner of -" - CTA'
properly who builds or,improves thereon,add who does such work FIXTURES-PER TRAP ;, 5.00 $o.Fr.FLOD�5AR�A TOTALACREAGE
himself or through his own employees,provided Thal such improve. O LIl/g41�f
merits are not intended or offered for sale.If,however,the budding r GAS EA.SYSTEM-11NC.4 OUTLETS'6.00 0 .
or improvement is sold within one year of completion,lite owner
builder will have the burden of proving that lie did not build or ul-' GAS-EA.SYSTE_M'-OVER 4 (EA'.) 2.00 BUILDING USE
prove for purpose at sale.). ' , RES IND- CON PB Other
er
❑. I,as ownof the property,am exclusively contracting with INDUSTRIALWASTE INTER. 30:00 0 E111 El 1-1. licensed Contractors to Construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6,00 ASSESSORS PARCEL NO.
and Professions Code; Fire Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.). 1.00 -
_ contracts for such proieets with a contractor(s)licensed pursuant to
the Con(facto[ SEWER-SANITARY-STORM V•s Lieensu Law. STORM EA.200ft/10.00 TRACT NO, PARCELNO.
❑ lam exdunp[Ruder see. ,n,xtr.c.for This
reason WATER HEATER W/VENT 6.00
' Owner '•Dole WATER SYSTEM 5.00 - Ace.DATE ACG FILE ND.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
hereby affirm that I have u certificate of consent In self-inaum,
of a ecrtil icam of.Workers'Compensation lnsurunee,Or a certil icd ' {' ZONING ENG.SITE NO.
copy[hereoffSec.3800,Lab.CJ.
Policy No. - Company '
❑ C�f1 fled copy is hereby furnished -
Z 2 �, 111!Certi tied Copy is
filed with the city'.inspection division.. FIRE SPRINK ENERGYT-24
2 Applicant MISC.- REFER TO ORD. Y 0 N❑ - Y ❑ N�
ir h 'CERTIFICA'fl?OF EXEMI'1'ION PROM WORKERS PERMIT ISSUANCE 10,00 FLOOD ZONE A.L.U.C.
LL > COMPENSATION'INSURANCE - PLG.CONTR LIC.NO.� 'r PLG.
EL O (This-section need not be completed if the pemlil is for one TOTAL YE) NC] Y E] NI[]
2 hnndrad dollars($1001 or Icss.)
U O 1 certify tear in Um performance if lite work to,which this pe UTV .MECHANICAL PERMIT EE FEE SUMMARY
LL F- mit is issued"I Shelf not employ any Person in Any Inunner so us Vr - I - F
O W become smbjad In[he Workers'Con..a,r ton Laws of California. I�
a Date 'APPlicant - ALTER OR ADD TO.MECH. 5.00 BUILDING
} N NOT 'f0 APPLICANT: If,lifter making this Certificate of Ex-
♦- Z Ltmption,you should become subject to the Worker,'Compemotion APPLIANCE 5.00 PLAN CHECK _
provisions of the Labor Cade, you most forthwith comply with FEE
V such provision's Doihis permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000 C.F.
�CONS'I'RUCIION'LENDING AGENCY, AIR HANDLING UNIT(OVER 10,000 C.F .) 6AD SEISMIC FEE j 8
I hereby affirm that there is a construction Icndinb agency for EXHAUST HOOD(WITH DUCT) 15.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.).' HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's'Name'
Lender,dAddress + HEATING UNIT IOVER 100,000 B.T.U.)9.50 ELECTRIC
l ardy Olaf lliuvc read this application onil D aic[flat the above V ENTILATION FAN (SINGLE) '4,00
infonnnllon is correct. I agree to comply with all city and county BOILER- H.P.or 100,0008.T.U.) 6.00 PLUMBING
ordinances and stale laws relating to building construction, and _
hereby entimn d representatives fori ins of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
hereby
nl enthmi7 property for inspection purposes to.
(We).II to save, indenmify and keep hanaless [he City of misc.- , r REFER D.
uperlino against liahilities,judgments, costs and expenses which 'PERMIT ISSUANCE CONST.TAX
may in anyway accrue against said City in consequence of the - l
rantingo is pennil. MECH.CONT. LIC.NO.' MECH.
_ TOTAL
2 / TOTAL L
Signalureuf Applicant/Contractor D to u - V� ey
OFFICE COPY