14563 (4) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
4UI LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 14563
-'1' ADDRESS-
e. U DING-ELECTRICAL-PLUMBING-MECHANICAL
DWNER'S I rod
NAME PLAN CHECK VALIDATION
CUNTHRCTOROT ELECTRIC PERMIT FEE
PHarvE
' {� -
NAME OUTLETS 10,00/1.00
O LIC.NO. / LIGHTING FIXTURES 10.00/1.00
CONTRACTOR
D
DRR ASTDRs Up�lnpff �_11117� PPLIANCES-RESIDENTIAL 4.00
PHONE - b6G PANELS 10.00
A CHI DATE OF APPLICATION
OR PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE PC.NO.
ENGINEER
LIC.No, SIGNS TRANS. 3.00
ARCH.OR ENG,
AOORESS SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
zm EMP. METER OR POLE INS. 20.00
ADDRESS TS MOTORS ' UKv SEEF
SERVICE CHANGE
zo.oD
_
r o o LICIiN51iU CON'1'RAC'I OIiS DECLARATION
a v U I h4tcby ufllent Ilial I an, licensed under Provisions.1Clupmo 9
w a n (commencing will,51e1lon 7000)of Division 3 of the Business and ISSUANCE GATE
BLDG. ELECT. PLG. MECH.
m Prole"Wo,Code.a red itlicense is in full lb�} :Wy1yJf' 17 r.�
a o n License Clms. y Lic.Nunda'r_(I-/_" ❑ ❑ ❑
4 r �4 Ume�=A��- Conn:mtm
a ¢ W u OWNER-BUILDER DL(LARAIION BUILDING PERMIT
w ;LL r I hereby affirm that I ant cacnpn 00... the Cnmraclor's Licens.. MISC.- REFER TO ORD INFORMATION
sDO Law for elle following nuson.(See.7071.5.Ilusina..undl•tofcvslon' PERMIT ISSUANCE NAwnnON E/FT.
Calc:Any city to count which rek LIJesa 10.00 Q �-
Yw Parmitwttmstnlcl.ullcq
m ¢ im Prove,d,nudis 1.ur repair'mry stnt,lun',polbr to i61ssllallee,also ELEC.CONI'li. LIC.NO. ELEC. �
A o u requires the upplicanl ful suc11 pellot it)tile file signed sllticlocnl ,,at TOTAL /U
e w m ha e licensed pursuant Io the Provisions of Ilia Contractor's License PERMIT TO
r Z a
Law Wha Pter 9(cummencing with Section 70001 of Divisiun 3 of the
Bwin.•ss and Poul6ssiuns(-o110 or(hat he i1.•scunit the"Gnul:Ind OTY. PLUMBING PERMIT FEE 4c=6e-C7
m r m the basis for the alleged"oull lion.Ali,violmion of Section 7031.5 STORIES TYPE CONSTR.
F_ bya-Y'PI'liwnt lar a penult subjons the;q+pli<am tuucivil penally ALTER-DRAIN & VENT-WATER (EA.) 5.00
of nal marc that,five hundre ($50
d dnlfun 01.)'.
❑ I,as owner of Ibe ruol,my,or my elupluyces with wage,us BACK FLOW PROTECT.DEVICE 4.00
Ihcio sole cump,b,,ticb,will do the work,and It,stru,h1wr l.nut OCC GROUP RES.UNITS
scented or o 'ered for sale (See. 7044, Business and Profemio"s DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code: tlno,Contractor, Li„lis,Law don nut uPply n,un Duvall rel'
property who build,or IIIgVovel the rum.,o ij who doe),o,h wo,Q FIXTURES-PER TRAP 5.0D
himself or through his own cbb,doyces.pnwOiled Ihzt .,Itinq.rove-
50.FT.FLOOR AREA TOTAL ACREAGE
moms are not intended or uttered for sale.11 however,lie building GAS-EA.SYSTEM-1 1NC.4 OUTLETS 6.00
\1_0or inp,rowmem is sold withinone Year u!cunt Pletmt the owner
builder will love the burden of pooling that he did not build or int- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ I,as owner of the properly,um unebuively tcu,R,cling with ❑ ❑ ❑ ❑ ❑
licensed con)ranors to construct m.• Project(See 7044, liusincss LAWN SPRINKLERS-1 INC 5 V.B. 6.00
and Professions Code:'Ilm Contractor's Liana•Lou'dues but uPp1y ASSESSORS PARCEL NO.
Ra an owner of pmperO who builds or intpruvcs thereon.and wilo LAWN SPRINKLERS-OVER 5 IEA.) 1.00
Contracts for such Projects-ill,a e.utral,woo licenwd pursuant In
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑
in esempt muter Sec. ,B.m1!('.iul This
sawn WATER HEATER W/VENT 6.00
Own.'r D.c WATER SYSTEM 5.00
ACC.DATE ACC.FILE N0.
W'ORKEkS'cOnIPIiNS,crID.N'DECLARATION' WATER TREATING EQUIP. 5.00
1 beret)'affirm That I h.oc a certificate of consent to svlFinsurc.
or a calif",of Workers'Cum pen"tion Inurt:uec,ora,crliiivd ZONING ENG.SITE NO.
ropyy�1E�rt� I(See lS 10,Lab.(./� {� j,,
Pulic)•If c_0_,"MomParty All 1 Ix+bkcj_
C)O ❑ ilre .up) a hereby lurnuhed.
❑ Certified• ry' is IIIc illi cil) lymc Don division. FIRE SPRINK ENERGY T-24
� O Appliculu_ �.y �-- MISC.- REFER TO ORD. r ❑ N❑ v ❑ N❑
CERTIFICA'ILOF Ii XI MPJ ION FkOM tvORKERS' PERMIT ISSUANCE 10.00
W D COMPENSATION IN'SURANCIs. PLG.CONTR. FLOODZONE ALU.C.
d O LIC.NO. PLG.
Z (This section bell bol be congslctcd if Ili, ...vmir is list ane TOTAL Y❑ N❑ Y❑ ry❑
UO hundred dwlurs(5100)or less.)
111 issu thus h the tc niplo)ce of ma work fur wblcll alis Per TY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mil is issued,I sin t nut w„piny' ce f the in why m:uich c,ns to
Q w become subject to the Workers'Cumpcnsuliou Laws of Calounia.
Den AANI': l ALTER OR ADD TO MECH. 5.00 BUILDING
} w N'O tion.'. shout(CAN'T: IC b",making(his Centime ul'I.,-
H2 eb,plimh,you should Co subject fothe t.Olovii(c.b,d,:won APPLIANCE 5.00 PLAN CHECK
pruvisiuns of the Label Code, you must Ionil wish comply with
U such pruvisiuns to mus permit shall be deetncd revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 FEE
CONS'('RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IQ 0C.F.M.) 6.00 SEISMIC FEE
I hereby affunn that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which itis Permit is issued(Sec.
3097,Cie.C6 HEATING UNIT ITO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name
Lender's Address HEATINGUNIT(O VER100,000B.T.U.)9.50 ELECTRIC
I cerlity that I haze read thus applicwuon and stale that the above VENTILATION FAN (SINGLE) 400
infonnutiow m .
n is correct. I agree comply will,all city and county PLUMBING
ordinances and '[all laws relating to building umLm,Oua, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authoriea opresenlalue, of Ihb city to suer upua IIT,
abuse-menimried property for inspection purpoO,s, BOILER-COMP (0vor 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree 1D save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
uparlunu against liabilities,juJgnnv,6, Curls and csprnsn whidl CONST.TAX
ay in any way accrue against said (:try in cunse'Derce of the PERMIT ISSUANCE 10.00
'r ul this Pen11I1, MECH.CONT. LIC.NO. MECH.
\/ p �- t' 6'-eg TOTAL TOTAL
J� Sj 1 ule IAP ruatt/Con ractur 1 re
OFFICE COPY