9359 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU6LDING PROJECT I DENTIFICATION PERMITNUMBER
ADDRES APPLICATION & PERMIT•
9359 n
ARRREss - `�`�
�O (f„? 2 Ss�✓(%(1/ApJ /J✓[' BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
• CfAetA / �1'«y PRONE�f�3o�
CONTRACTOR UTLET3-SWITCHES-RECEP 10.00/1.00
`°''e%'F� 4 e0 •4T. LIC.NO. 1F38�QL LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S
A�RESS p PPLIANCES-RESIDENTIAL 4.00
la7 /V3 "sT. S.) PHONEAgl __7J"`I_) PANELS 10.00 DATE OF APPLICATION
OR
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.N0.
ENGINEER
LIC.NO, SIGNS TRANS. 3.00
ADDRESS ENG. PERMIT CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 f3t9..
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH.
SERVICECHANGJZ, 20.00 i
° ¢ TEMP.POLE - 30.00 /�Af6DA/TE OO LICENSED CONTRACTORS DECLARATION1 hereby afrom that I am licensed under provisions ofChapter 9a T (commencing with Section 7000)Of Division 3 of the Business and IB
o r I fill
O m Professions COdu,agld my license is N,lull for Hfeo2 s BLDG. ELECT. PLG. ME❑C H.
0 O,7, Licenu Cls_9 /, Lica Number eF
Z
If Contractor vWf Goal City Q)c Cup
lr EY 1 lr BUILDING PERMIT
sc a OWNER-BUILDER DECLARATION ertinQ
A o o INFORMATION
w g m 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TS ORD
of Law for the following reason.(Sec.]031.5,Business and Professions PERMIT ISSUANCE1D-QO VALUATION S/FT.
f ">f Code:Any city orcounty which requires a permit to construct,alter, p�
KM 4 ° improve,demolish,or repair any structure,prior kin its issuance,also ELEC.CONTR. LIG NO. ELEC.L /V✓
sc w m M requires the applicant for Such permit to file a signed statement that TOTAPERM( TO
he is licensed pursuant to the provisions of the Contractor's License -
FiQLaw(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe TQM�/ 4 LET+
Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE /
H $ the basis for the alleged exemption.Any violation of Section 7031.5
u ;_ by any applicant for a permit subjects the applicant to a civil penalty STORIES TYPE CONSTR.
of not mom than five hundred dollars(S500),): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00
their Mile compensation.will do the work,and the structure is not OCD.GROUP RES.UNITS
intended or offered for sale (Sea 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 se.Fr.vLooR AREA TOTALACREAGE
AX• himself or through his own employers,provided that such improve-
or
are not intended o offered lorsele.If.however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
prove for Purpose ol'sale I INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to instruct the project(See 7044,BusinessLAWN SPRINKLERS- 1 INC 5 V.B. 6.00
and Professions Code:The Contractor's License Law does not apply ASSESSORS PARCEL NO.
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contraclor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACTNO. PARCEL NO.
❑ lam exempt under Soc. ,B.&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00
ACC.DATE ACG FILE NO.
WORKF:RS'COh1PF;NSATION DECLARATION WATER TREATING EQUIP. 5.00
1 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.)..T4&P4/1Mt-4 r-C/P
POlicy No. Company
O ❑ Certified copy is hereby furnished.
Z Z ❑ Certified Py 's Bled with the city' nspectmd division. FIRESPRINK ENERGYT-24
F- y j pplicl... /.T//L� c eM(h MISC.- REFER TO ORD. Y ED NE] Y [] No
CC - CERTIFICATIi 017 EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.D.
LU > COMPENSATION INSURANCE: PLG.CONTR. LIC.NO.
d 0PLG.
� Z (rd, section need not be completed if the permit is for one TOTAL v N� Y 0 NE]
hundreA dollars 1$1001 or lc,,,)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE SUMMARY
LL U mit is issued,I shall riot employ any person in any manner so as to FEE
O W become subject lin the Workers'Compensation Laws of California
y Date Applicant
>_ to DateNOTICE TO APPLICANT: If,alter making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00 BUILDING
Z eprvisions Of the Labor Code, you must forthwith comply with mption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
o
U such provisions or this permit shall be deemed revoked FEE AIR HANDLING UNIT(TO 10=11F.M.) 4.00 '
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.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.
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name
Lender's Address HEATI NG UN IT(OV E R 100,000 B.T.U.)9.50 ELECTRIC /
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
. information is correct I agree to comply with all city and county BOILER-COMPLUMBING
ordinances and state laws relating m d (3 H.P.H.Pbuilding construction, anor 100,000 B.T.U.1 6.00
Lo
authorize repres natives of this city to enter upon the
cmioned grope y rinspection purposes. BOILER-COMP (Over 100,000 BTU(SEE FEE SCH. MECHANICAL
agree m v, emnif and keep harmless the City of MISC.- REFER TO ORD.
o again li hes,j nents, costs and expenses whichCONST.TAX
any aga' s said City in consequence of the PERMIT ISSUANCE 10.00 of I MECH.CONT. LIC.NO. MECH.
67 $� 8f TOTALTOTAL
e ol'Applica Contractor Date
OFFICE COPY