18814 (2) APPLICANT TO'FILL IN INFORMATION WITHIN REDLINES — USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION ,PERMIT NUMBER
.LILDING APPLICATION & PERMIT ° 18814
REs ^
BUILDING — ELECTRICAL—PLUMBING—MECHANICAL y.
WN[R'S
E PLAN CHECK VALIDATION
DTV. ELECTRIC PERMIT FEECONT '
NAAMERacTDfls � 5� UTLETS-SWITCHES-RECEP 10.00/1,00
LOC.No, LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S APPLIANCES-RESIDENTIAL .4.00
DDflE55
PANELS 10.00 DATE OF APPLICATION
0.CRI1ECT PANELS IOVER 200 AMP) 20.00 PLAN CHECK FEE P;C,,NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ADDRESS ENG SPECIAL CIRCUIT 5,00 - PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 „�"7�
ADDRES
ASS MOTORS SEE FEE SCH.
OREA
SERVICE CHANGE _ 20.00
woo LICENSED CONTRACTORS DECLARATION
¢ 1 herehy affirm[hal am licensed under provisions of Chapter 9 YI/-fly { a„�`�
(commencing with Section 7000)of Division 3 of the Business and ISSUANCE DATE
rj 2 Professions Calk,and y license is in full force' ef(•c BLDG. ELECT. PLG. MECH.
Zo z m Licensor — Con ractorr - - I lit . I
Dore Contractor rm-r�G
Y - BUILDING PERMIT
a ¢ w owmat-Bun.1iER DECLn Rp1'1oN INFORMATION
w3: LL y 1 hereby affirm that I am exempt from the Contractor's License MISC:— REFER TO ORD
H u o j Law for the following reason.(Sec.7031.5,Businessu id Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
Code.Any city orcounty which requires a permit to construcl,alter,
22 ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
¢ requires the applicant for such permit to file a signed statement that - TOTAL
n
or m he is licensed pursuant to the provisions of the Contractors License PEO
TO
r z i Law(Chapter9(commencing with Section 70001 Of Division 3 ofthe
a Business and P,ufessiuos Code)or[far he is exempt Iherefrom and OTY. PLUMBING PERMIT FEE
M I$ the basis for the alleged exemption.Any violation of Section 7031.5 S ORIES TYPE CONSTR.
wT� byany applicant for it Permit Subjects the applicant toa civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(55001.):
❑ I,as owner of Ole property,or my employees with wages as BACK FLOW PROTECT. DEVICE 400
their sole compensation,will do(lie work,and the structure ue is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of '
properly who builds Or Improves IIICICDn,and who does Such work FIXTURES-PER TRAP 5.00 SD.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such Improve.
mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
_ or improvement is sold within one year of completion,Ore owner.
builder will have Ole hurden of proving that he did not build or ins- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON Pa Omar
❑ I,as owner of the property,am exclusively'eonimeting with 0'
licensed contractors to construct the project(Sec. 7044,Business LgWN SPRINKLERS-1 INC 5 V.B. 600 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License.Law does not apply .
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00 _
contracts for such projects with a contortions)licensed pursuant to -
theContractor;LicenseLaw. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,H.&P.C.I'or this WATER HEATER W/VENT ..6-00
on p
Owner Dale WATER SYSTEM 5.00 ACC.O.ATE -ACC.FILE NO.
WORK FRS'COMPENSAT1ON 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(Sec.3800,Lab.C.).
Policy N.. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY P20
Z Z p� Certified copy is filed with the city inspection division.
O ApS icant MISC.- REFER TO ORD. Y 0 N.❑ Y ❑ IN
1600
• CI:RTI FICA ION PERMIT ISSUANCE •(� FLOOD ZONE A.L.U.L.
LidCOSATION
W � COMPENINSURANCE - PLG.CONTR. LIC.NO.
CL O 1'[his section Rall not be completed if the permit is for one TOPLG.TAL I/q6n Y N Y[3 N
Z' hundred dollar,IS 100)or less.)
U O 1 certily that in the performance of lire work for which this per. CITY MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued, I shall not employ any person in any Runner was to
O L) become subject to the Worked Conipensut ion Laws of California. -
tL Dale Applicant BUILDING
} rn NOTICE TO APPLICANT': If,after nuking in,Certificate of Fix- ALTER OR ADD TO MECH. 5.00
F Z emphan,you should become Subject to the Worked Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
U such provisions or this penult Shull be deemed revoked- AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 FEE
CONST'RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
I 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(Sec. MICROFILM
3097,Civ C.), HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's e
a
NmHEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Name - ELECTRIC
I certify that l Have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING ,U
ordinances and Stall laws relating to building construction, and BOILER-COMPI3 H.P.Or 100,0006.T.U.) 6.00
10 hereby authorize representatives foriins of this city to enmr upon tb° BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned authored properly tativsp of
ection purposes.
(We) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
s. upertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
LU'ytin
any way accrueagainst said City in consequence of lireO([his rmlt' MECH.CONT. C.NO. MECH.
y TOTAL TOTAL r`e of Applicant/C actor Date - V
OFFICE COPY