16258 (5) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES' USE BALL POINT PEN ONLY
:.6UI LDI NG PROJECT I DENTI FICATI ON .PERMIT NUMBER
BUILDING
aooREss / �.�SJ,Ln APPLICATION & PE_RMIT
�/q-� BUILDING -ELECTRICAL-PLUMBING-'ME
CH'ANICAL 1. 62.5.8.
OWNERS
NAME ° QTY. ELECTRIC PERMIT- FEE
: PLAN CHECK VALIDATIONNI •4,,✓ate- CHONE r
CONTRACTORS
NA^E,^� UTLETS-SWITCHES-RECEP. 10.00/1.00 -
W LIC.No. 7 L LIGHTING FIXTURES 10.00/1.00
CONTRACTOR - .APPLIANCES-RESIDENTIAL 4.00 '
CONTRAS amsI \ Q
/ �'• e '�3�'VPHONE C) PANELS 10.00 , DATE'OF APPLICATION
ORcwiEGT PANELS'(OVER 200 AMP) ' 20.00 PLAN CHECK FEE
ENGINEER ..
LIC,NO. SIGNS TRANS. '• 3.00 '
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00 - - -
ZIP TEMP.METER OR POLE INS, 20.00
APPLICANT'$
ADDRESS MOTORS SEE FE
SERVICE CHANGE 0.00 ',"P
oaz
_ Foo LICENSED CONTRACTORS DECLARATION
a u u I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
vHi Q H (Commencing With Section 70001 of Division 3 of the Business',md BLDG. .ELECT. PLG. ^MECH.
r m t Professions Code,and my, icense is in full fore �d eff�1�7 ❑ ❑ ❑
z o m- License l.ic.Number -
o an w Dote ConlructmC -
a'oa E " OWNER-BUILDER - BUILDING PERMIT
¢ a w DECLARATIONse I hereby affirm that I:un exempt from the Contractor's License MISC.- -REFER TO ORD INFORMATION
u o Q Law for the following reason.(See.703 1.5,Businessand Professions PERMIT ISSUANCE VALUATION $/FT.
5NO'o Cade:Any city or county which requiresa permit to conslrucl,alleq IZ•oD ttrOQZ .
SE2¢'2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. '�:?j
a
¢ requires the applicant for such permit to file a signed'statement that �� C- I7 L TOTAL/,F!1
e. PERMIT TO -
P,mQ he is licensed pursuant In the provisions of[tic Contractor's License
Hi
Law(Chapter 9(commencingwith Section 7000)of Division 3ofthe -
4 O
business and Prol'L"nons Code)or thud he Isexempt theist......and QTY. ,PLUMBING PERMIT
¢ rro the basis for the alleged exemption.Any violation of Section 703 LS _ V ORIES TYPE CONSTR:
a3 _ by any applicant for a permit subjects the applicant to a civil rurally ALTER-DRAIN IEA.) 5.00 +
of not more Ilion five hundred dollar,($500).)-
❑ I,ns owner of the properly;or my en.ploydes wish wages as BACK FLOW PROTECT. DEVICE - 4,00 - OCC.GROUP RES.UNITS
their sole con.pensation,will do the work,and the st umurzs is noC
intended or offered for are (Sec.-7044, Business and Professions DRAINS'FLOOR;ROOF,AREA,-COND. 5.00 -
Code:The Contractor's License Low docs not apply to an owner of
. property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
Ilimrelf or through his own employees,provided that such improv.
...ems are not intended or offered for sale If,however,file building GAS-EA.SYSTEM-1INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or all- BUILDING USE
move par purpose ofsWe.). INDUSTRIAL WASTE INTER. 30.00 - RES wD core PB ower
m
❑ 1,as owner of the property,am exclusively conducting with ❑. ❑ ❑ ❑ ❑
licensed contractors to construed the project(Sea 7044,BusinessLAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The 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 projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.2004/10.00 TRACT NO. PARCEL NO..
❑ I am exea.ptunder Sec. ,B.&P.C.for thisWATER HEATER W/VENT 6.00 '
reason
Owncr Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSAT'ION.DECLARAIION WATER TREATING EQUIP. 5.00
I hereby affirm that I have it certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG,SITE NO.-e _
copy thereof JJ,,Se�a�3 00,Lab.C.): s
PolicyND.flCg'mS�un,panr-�£PI 1ALJ i13 D• . .
0 O Certified'copy is hereby furnished. - FIRE SPRINK ENERGY T-24
z Z Certified �y1 �Is filed with the t inspection division. ❑ ❑ ❑ ❑
H O A(fplicou TIC't6.a-/at; �''/- rTaGIC MISC.- REFER TO ORD. Y N Y N
CC rn CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.c.
Lu > COhIPENSWION INSURANCE PLO.CONTR. LIC.NO. PLG,
Q. 0 (.'his section need not he completed-it'the pedal is for one TOTAL Y❑ N❑ Y❑ N❑
Z hundred dollars(SI00)or less.)
U O, 1 certify that in the performance of the work]or which this per- 'QTY MECHANICAL PERMIT FEE 'FEE SUMMARY
LL H OIL is issued,I shall not en.ploy any person in any manner so as to '
U become subject to the Workers'Compensation Laws of California.
.0 a Date Applicant ALTER OR ADD TO MECH. - 5.00 BUILDING
.} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F ? emotion,you should become suhjcel to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
- provisions of the Labor Code, you must forthwith comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) ,4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000GEM.) 6.00 - SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT)' 5.00
the perfornl:u.ce of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CU. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name' HEATI NG UNIT(OV ER 100,000 B.T.U.)9.50
Lender's Address - � ELECTRIC � •�
I certify that Ihave 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 -COMP(3 H.P.of 100,0008.T.U.) 6.00 PLUMBING
ordinances and state laws,relating to building construction, and BOILER '
hereby authorim representatives of this city Io clue, upon the BOILER-COMP IOv r 100,000BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purpnscs:
,(We) agree to save, indemnify'and keep harmless the City of MISC.-. - REFER,TO ORD.
against liabilities,judgments, costs Laid expenses which CONST.TAX
Lilly in it y way-accrue against said Ci . cn - ce of the PERMIT ISSUANCE - 10.00
ranting ftllispennit. MECH.CONT. LIC.NO. MECH. ' .
�n TOTAL TOTAL
ore of Applicant/Contractor
OFFICE COPY