11912 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
i BU I LDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDINGpi&u1 ` APPLICATION & PERMIT 11912
(J dP (�'�
1y, -C •rA(A BUILDING -ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S PLAN CHECK VALIDATION
rvA OTV. ELECTRIC PERMIT FEE
(iV�// PHONE
CONTRACTOR'S /� OUTLETS-SWITCHES-RECEP 10.00/1.00
Irug /�-01•I (Q.iG • uc.No.Y hZ�/^ LIGHTING FIXTURES 10.00/1.00
roNTRacroRI•s 1I/1 11 /,�q'///� x�/j / PPLIANCES-RESIDENTIAL 4.00
s� YY17tjEgl� PHONE / /-I��/r/(/ PANELS 10,00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ENG, SPECIAL CIRCUIT S.00 PERMIT VALIDATION
ARDEss
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS u-MOTORS 1�F•EAEEE SCH.
_ e
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION r I �Ol
a vw I hereby affirm that I am licensed under provisions of Chapter9 ISSUANCE DATE
H¢ uwi (commencing with Section 7000)of Division 3 of the Business andp �s BLDG. ELECT. PLG, MECH.
Hwa Professions Co a' my license is'in(all IirrAyU�Vf1 t. ylty of Ls1ir3fflIID ❑ ❑ ❑
oi m o License Class
r W Data- COntmCt�o�ILQQ-.C()AI_
xE BUILDING PERMIT
Ic wOWNER-BUILDER DECLARATION INFORMATION
K 3 °'H I hereby al tion that I am exempt from the Contructoi s,License MISC.- REFER TO ORD
1° u o as Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 Q VALUATION $/FT.
0 Code:Any city or county which requiresa permit to Construct,alter,
R Li ¢Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEG (4f L�p
- I] M requires the applicant for such permit to file a signed statement that TOTAL / 6
X
$ he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
ii Law(Chapter 9(commencingwith Section 7000)ofDivision 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
Eio
W H the basis for the alleged exEmption.Any violation of Section 7031.5 - STORIES TYPE CONSTR,
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale(See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SG.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
menta are not intended or offered for sale.IG however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or ins-
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB anter
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-I 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 iLAWN 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.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
W'ORKERS'COMPENSATION DECLARA'T'ION 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.lA.�.
Poli No. Company
Q Certifie py is hereb furnished. FIRE SPRINK ENERGY T 24
Z p plicpnrtifi is4H Fvrph.Vhe city inspection division. MISC.- REFER TO ORD. y ❑ N❑ Y ❑ N❑
w -XEM r1 PERMIT ISSUANCE 10.00
- CI1R IPICAT'01'fiXEMI'TION FROM WORKERS' FLOOD ZONE A.L.U.C.
W COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG. '
(L Z( This section need not be completed if the permit is for one TOTAL 17Y EE] N❑ Y [:] N❑
hundred dollars(S 100)or less.)
U O I certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL. I- mit is issued, I shall not employ any person in any manner so as to U become subject to the Workers'Compensation Laws of California.
La Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICETO APPLICANT', If,atter making this Certificate of nix.
F Z
caption,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
Provisions of the Labor Code, you most forthwith comply with FEE
C.1 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10p)0C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby afOrm that there is a construction lending agency lot EXHAUST HOOD(WITH DUCT) 5.00
the Performance of(he work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's NaMICROFILM
3097, 1.s Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
( certify that have real this application and slam that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relining to building construction, and BOILER-CO MP(3 H.P.or1O0,000B.T.U.) 6.00
hereby authorize representatives of this city I. enter upon the BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly for representatives
inspection i purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cape against liabili' ,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may i y w, c e u In said City in consequence of the
gm i per L MECH.CONT. - LIC.NO. MECH,
b e1• TOTAL TOTAL
Signaturey Applicant/Contractor Date
OFFICE COPY