11440 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY /l 33 y
BUILDING PROJECT I DENTIFICAT PERMIT NUMBER
BUILDING APPLICATION & PER
A,ORE" ///^�'�
f I/16t4ol (ter' BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
11440
OWNER'$ PLAN CHECK VALIDATION
•'
I AiA..`+ HorvE 973,70 OTY. ELECTRIC PERMIT FEE d,-, v
c TRac- R' OUTLETS-SWITCHES-RECEP 10.00/1.00
i
LIGHTING FIXTURES .10.00/1.00
r-ONTRACTOR' APPLIANCES-RESIDENTIAL 4.00
A DOREss - slC
' yA W C
2� O r PHONE YQO� O� PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) ZO.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER o
L L uc NO SIGNS TRANS. 3.00
neo Ess ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 )
ADDRESS MOTORS SEE FEE SCH. Q (`�xj',A^1"li-'f✓
SERVICE CHANGE 20.00
O o o LICENSED CONTRACTORS DECLARATION
a v I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
w< y (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
rD z Professions C e l a is in full for ferut
z o y License C{aass 7ls E.Number ❑ ❑ ❑
9 y- Date1�� ontrucmr �
y BUILDING PERMIT
R m w OWNER-BUILDER DECLARATION INFORMATION
o le MISC.- REFER TO ORD
w m I her by affirm that 1 am exempt from the Contractor's License
VAWATION $/FT.
Fu04 Law for ¢following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any 'ity or county which requires a permit to construct,alter,
f w ELEC.CONTR. LIC.NO.
a 2 ¢O improve,de lisp,or repair any Structure;prior to its issu 'e,also ELEC.
G LL requires the ap cant for such permit to IIIc a signed sla ent that TOTAL PERMIT T,O
i J/7/
w$ he is licensed to. ant to the provisions of the Contra or's License
Iczi Law(Chapter 9(co ening with Section 7000)of ision3 of the �'Z
a Business and Prolbssi Code)or that he is exem therefrom and DTV. PLUMBING PERMIT FEE
$ the basis for the alleged emption.Any violatio f Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a pernsubjects the appli nt toa civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundre ollars($500).
❑ 1,as owner of the prope ,or my a loyees with wages as BACK F LOW PROTECT. DEV ICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do a work and the structure is not
intended or offered for sale(Sec. 44 Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law s not apply to an owner of
Property who builds or improves the o and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employ s,pr 'ded that such improve-
menlsarenotintendedoroffered or sale.II oweven tire budding GAS-EA.SYSTEM-I1NC.40UTLETS 6.00
or vnprovement is sold within a year of co ktion,the owner GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden proving[hat he not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Orn.r
❑ 1,as owner of the perry,am exclusively cc ratting with ❑ ❑ ❑ ❑ ❑
licensed contractors to nstruct the project(Sec. 70 ,Business LAWN SPR IN KLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code: a Contractor's License Law does of apply
to an owner of pro ly who builds or improves thereon. d who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such rejects with a contractors)licensed pursu it to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's itense Law. TRACT NO. PARCEL NO.
❑ lam ex pt under Sec. ,B.&P.C.for it WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(See.3800,Lab.C.).
71 Policy No. Company
0x❑,/Certif, Is hereby urni, ed. FIRE SPRINK ENERGY T44
Z 2 pl,Certifie c 's II w' ity irspection division.
MISC.- REFER TO ORD.
O_ PPlicant v❑ N❑ v ❑ No
CC Lo CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.C.
W > COMPENSATION INSURANCE PLC.CONTR. LIC.N0.CL PLG. v❑ N❑ Y ❑ N❑
Z his section need not he complete) if the permit is for one TOTAL
han r rs IS 100)or less.)
U O 1 certify that erformance of the work for which this per- O 'MECH ID PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall note any person in any manner so as to V
U become subject to the Workers'Co oa Laws of California.
ED Date Applicant ALTER OR ADD TO ME 5.00 (711 BUILDING
} y NOTICE TO APPLICANT: If,after making this Certificate of Ex-
♦- z emption,you should become subject to tine Workers'Compensation App LIANCE 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. 2 AIR HANDLI G UNIT IT
10 .M.) 4.00, �eUO
CONSTRUCTION LENDING AGENCY AIR HANDLIN C.F.M.) 6.00 SEISMIC FEE
I he ffirm that there is a commDedcn lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the 3097 erC10 C'nc he work for which this permit is issued(Sec HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 NVQ
information is correct. I agree to comply with all city and county PLUMBING
'• ordinances and state laws relating to building construction, and BOILER-COMPO H.P.or 100,000 B.T.U.) 6.00
hereby autlmrize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE$CH. MECHANICAL
above-mentioned property for inspection purposes.
(W me to save, indemnify d keep harmless the City of MISC.- REFER TO ORD.
Cu i gains) liabilities,jud ts,costs and expenses which' CONST.TAX
y y way accrue yg�mst s Id City in consequence of the PERMIT ISSUANCE 10.00 /Q-UDa i g f[his rmiL Y/ ME .CONT. UQ NO. MECH/f TOTAL3c� TOTAL
at re of Applicant/Cooloot Date
OFFICE COPY