12601 (2) h
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENT[FICATION PERMIT NUMBER
7t no'taess ) � APPLICATION & PERMIT
'ifl�� / ,V YOQ BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
12601
/ OWNER'S ,l PLAN CHECK VALIDATION
N" E ,T QTY. ELECTRIC PERMIT FEE
MIr,�' kM1 �J PHONE ��G_J /2G
RrA Toas ,/ UTLE-S-SWITCHES-RECEP 10,00/1.00
el�Af C !, - 'Ve- 37o i 4
Ic.rvO. LIGHTI N'.G FIXTURES 10.00/1.00
CONTRACTORS III PPLIANCES-RESIDENTIAL 4.00
ADDRESS
u A/lK/e q No6U E -S_S'- PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
DR Zq-/1 ef)�f- PANELS (OVER 200 AMP) 20.00
ENGINEER (/
. uc,NO ISIGNS TRANS. 3.00
ADD'Ess ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
AMOTORS - SEE FEE SCH.
ADDRESS DOREss '
SERVICE CHANGE 20.00 vY'09 LICENSED CONTRACTORS DIiCLA RATION
rt it w 1 hereby affirm that am licensed under provisions of Chapter 9 ISSUANCE DATE
N 4 w (commencing with$ Ion 7000)of Division 3 of the Businesa anJ - BLDG. ELECT. PLG. MECH.
H h a Professions C de, y license is in full(ores
z o H - Licensee Number - 0 El 1:1o Con
r Date Contractor
P: m BUILDING.PERMIT
¢ ¢ ¢ OWNER-BULDHR DECLARATION.
o a D INFORMATION
w 3: I- I hereby affirm that 1 am exempt from ilia Contractor's License MISC.- REFER TO ORD
$/FT.
H _ o a Law for the following reason.(Sec.7031.5,Business and Professions VALUATION
PERMIT ISSUANCE 10.00 �
Code:Any city or county which requires a permit to construct,alter, _2'
2 al
is < FO improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC. xr "r-_I -
LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
E
$w he is licensed pursuant to the provisions of the Contractor's License
H z ) Low(Chapter 9(commeneing with Section 7000)of Division 3 of the �q 7RES.
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMITG¢ r $ the basis for the alleged exemption.Any violation ofSection 7031.5 STORIES TR.by any applicant for a permit subjects the applicant too civil penalty gLTER-DRAIN&VENT-WATER IEA.15.00
of not more than five hundred dollars($500).):❑ I,as owner of the property,or my employeeswith wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP S
their sole compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5,00
Code: Tire Contractors 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 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
meats are not intended or offered for sale.If,howeveq the building GAS-EA.SYSTEM-l1NC.40UTLETS 6.00
'•� or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or int. BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Orher
❑. 1,as owner of the property,am exclusively contracting with 0 ❑ 0 0
licensed contmclors'lo construct the pricer(Sea 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. -6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs not apply
In an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITAR V-STORM EA.2001t/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&BC.for this WATER HEATER W/VENT 6.00
reason
.Owner Data WATER SYSTEM 5.00 ACC.DATE ACC.FILE N0,
WORKF-RS'COM PENSATION D17CLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate at consent to self-insure, ZONING or a Certificate of Workers'Compe U�/r�nn n umnce,or a�cc I fied ENG.SITE NO.
,isCOPY thereof(Sec.3800,Lab.CJ v �Zr /pPy,�'r
Policy No. Company G
Z ❑ Certified copy is hereby fur shed. FI RE SPR INK ENERGY T-24
6�Qaroified copy is fled with the city inspection divi, out MISC.- REFER TO ORD.
O Applicant Y E] IN Y E] NE3
1-
ccy- PERMIT ISSUANCE 10.00 CE EICAT'F.OP EXEMPTION FROM WORKERS' ZONE A.L.U.C.
LU J COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG,
CL D ffhis section need not be completed if the permit is for one TOTAL Y❑ NE] Y ❑ N
D Z hundred dollars(5100)or less.)
U O 1 certify that in the perl'onnance of the work for which this per CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL - mut is issued,I shall not employ any person in nny,manner so as to
O Ca become subject to the Workers'Compensation Laws of California.
a Date ApplicantALTER OR ADD TO MECH500 BUILDING J
} to NOTICI7'1'O APPLICANT: If,after making this Certificate of I!x . .
--
F ? emprou,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
C.1 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000C.F.M.) 6.00 -SEISMIC FEE
I hereby affirm thatthere is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued fSee. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name H EATI NG UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address - ELECTRIC
. Icertify that l 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-COMP(3 H.P,of 100,000 B.T.U.1 6.00 PLUMBING
ordinances and state laws relating to building construction, anJ
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cuper[inp�ainst liabilities,judgments co sand ex ansa.which CONST.TAX
may it ly way accr again. el�t in on e acne of the PERMIT ISSUANCE 10.00
gran g N this perrslit. MECH.CONT. LIC.NO. MECH.
Y B� TOTAL TOTAL db
Ignature of Appli t/Contractor Date •�
OFFICE COPY