6781 (2) / APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY �
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
Y 7` olILDI G,/UO/DR_SS - .S, Sga9-TOo4 Sl- l yl,k 4*l APPLICATION & PERMIT
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 6781
OWNER'S (v} - PLAN CHECK VALIDATION
` NAME qv V y& t t i. : ,
Soo f'i, 99y QO�47avt7to � JJ O-0)"ID
OTYJ. ?ELECTRIC'PERMIT= ' " FEE,!,
PHONE J�I
. ,NAMERAcroRs OUTLETS-SWITCHES-RECEP 5.00/1.00
SoJ'�k Q9 Co JsTnJc'Tro
Y
LIC.NoBl -313 V 394JILIGHTING FIXTURES 5.00/1.00
AooFEs@crGR's - PPLIANCES-RESIDENTIAL 4.00
6// O�VWo-. Sy-. O.q...p4//ONE J$-O VD PANELS 5.00
3 DATE OF APPLICATION
RCHrtF<i SIGNS -6.00 PLAN CHECK FEE P.C.NO,
O
OR
ENGINEEH
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ervc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION.
ZIP TEMP.METER.OR POLE INS. 15.00 -
APPucArvr's - MOTORS - SEE FEE SCR.
ADDRESS
PPLICA
SERVICE CHANGE 10.00 �/ F
0 0 0 LICENSLD CONTRACTORS DECLARATION ////re-
a v I hereby affrm that I an licensed underpmvisionsof Chapter 9 ISSUANCE DATE
vHi a W% (commencing with Section 70001 of Division 3 ofthe Businessc'd BLDG. ELECT. PLG. MECH.
H y z P ofessions Code,s}�nn�sj7 my license is in full for yqgqQQ��e c-t .❑ ❑ ❑
OCa., lass.s-6_/__I.R.Numbc,�2 fly�.
H )ate��pvs,�Contractor<n J�-r[ /}g./
m a OWNER-tlUILDIiR DL'CLARATTUN�aCTr�v' r -,gBUILDI `PAERMITS�"
a o a ° jW'C;'INFORINATIONJ�"
x ;u N I hereby affirm that I am exempt from the Contractor's License MISC.- -REFER TO ORD -
"' u 0¢ Law for the following reason.(Sec.7031.5,Eusinessand Professions - VALUATION $/FT.
PERMIT ISSUANCE g-Op - 1n�^
Code:Any city nr county which requires Permit to construct,alter, J 'i
QQQ0improve,demolish.orrepair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEG r
_ O ac reclaims the applicant for such permit to file a signed statement that TOTAL
d w m he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
r'Z a Law(Chapter 9(commencing with Sect ion 7000)ofDivision3ofthe i. - CkEB jA Y�Q��
4 D Business and Professions Cade)or that he is exempt therefrom and QTY.;.a`� ea p PLUMBING^PEflM1T 4l ((
M F pm the basis for the alleged exemption.Any violation of Section 703 t.5 STORIES TYPE CONSTR.
by any applicant for It permit subjects the applicant macivil penalty. ALTER-DRAIN -WATER (EA.) 4.00
of nor more than five hundred dollars(8500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
(Imir Sole compensation,will do the work,and the structure is not
intended or offemd for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Comna,mr's License Law does or apply to ua owner of
property who builds or improves thereon,and who does such work FIXTURES"-'PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
� himself or through his own employees,provided that such improve.
- meats are not intended tar offered for sale.l f,however,the building GAS-EA.SVSTEM,-11NC.40UTLETS 4.00 -
or ,rprovement is sold within ane year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.)
buiilder will have the burden of proving that he did tint Build or im- 1.00 BUILDING USE
prove for,purpose of sale.). INDUSTRIAL WASTE INTER2000 RES 'IND CON PB Other
❑ I,as owner of the property,a o exclusively contracting,with . .
❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCELNO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWNSPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
the CeRilrgctor's License Law. - SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
❑ Iambxemptunder Sce. - ,RAP.C.for this WATER HEATER W/VENT 4.00
reason
Owner Dare WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby;(iron that I have a cerlil'icate of consent to sal Ginsure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO,
copy thereof(Sec 3800,Lab.C.).
Policy Na. Company
O' , ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T$4
Z, ❑ Certified copy is filed with the city inspection division. MISC.- REFERTOORD.
(1-F Applicant Y El E] Y [D N[3~ v� CIRTIPICI EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00
FLOOD ZONE A1.U.C.
LU COMPENSATION INSURANCE
PLG.CONTfl. LIC.NO. PLG.
d 0 (This section need not be completed if the Pe nn it is for one TOTAL v EJN❑ Y❑ N❑
=) Z hundred dollars IS 100)or Ices.) - - s �.
L) 0 I certify that in the performance ol'the work for which this per- DTV. 1' MECHANICAL PERMIT FEE FEE SUMMAflV'r
LL I. mit is issued, I shall nor employ any person in any Canner so as to
OL) became subject to the Workers'Compensalion Laws of California.
Uam Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} Ea NO'fICF- 'f0 APPLICANT: If,atter making this Certlfica(e of Ex-
Z emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisinns of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1OA00QF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that (here is a construction lending agency r'or EXHAUST HOOD(WITH DUCT) 2.00
(he performance of the work I'or which this permit is issued(Seo. - MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lenders Addr HEATI NG UN IT ER 100,000 B.T.U.)7.50 CLO
Lender's Address ELECTRIC
I curtly that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county g01LER-COMP(3 H.P.Of 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building,construction, and
hereby authorise representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP(Over 100,000 BTU)SEE FEE SCM. MECHANICAL
(We) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
C
(we.)
against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
ay, In any way/kers against In City in consequence of the
grand of Is Er L MECH.CONT. LIC.NO, MECH, i
TOTAL TOTAL
Signatur ul'Applieant ontractor Data
OFFICE COPY