2477 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
AOODEa �^�.,��
77
q7 5TEUtENS Cgjso :K BUILDING - ELECTRICAL-PLUMBING-MECHA,NIC.�AA LL 1.�
NAM R's ^:s - r .CTn„'a k.1rv' �' TINT
NAME y� YC 'Q VM PLAN CHECK VALIDATION
LorJL6lniS�l� PRONE ZSS IV
ELECTRIC PERMIT r �y'NAMESWITCHES-RECEP 5.00/1.00
sec.NO. FIXTURES 5.00/1.00
ADDRRessiOR'sS-RESIDENTIAL 4.00
PHONE 5.00 DATE OF AP PLICATION
ARCHITECT PLAN CHECK FEE P.0 NO.
Ga SIGNS 6.00 O�
ENGINEER
sec.NO. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANT
TS
ADDRESS MOTORS SEE FEE SDH.
SERVICE CHANGE 10.00
Doi
Foo LICENSED CONTRACTORS DECLARATION
<U v I hereby affirm that 1 am licensed under provisions of Chapter 9
y a eAi (commencing with Section 7000)of Division 3 of the Business and ISSUANCE GATE
I-H or Professions Code,and my license is in full force and effect. BLDG. ELECT. PLG. MECH.
zo i w C License Class Lic.Number fI��II
u J Dale Contractor I� ❑ ❑ ❑
a a w OWNER-BUILDER DECLARATION f3'�i"¢`<ro BUIL"DINOPERMIT.`-z'"¢,F.:
W ;LL N 1 hereby affirm that I am exempt from the Contractors License MISC.- REFER TO ORD :;+._4,INFORMATION;`1'
u o< Law for the following reason.(Sec.703 1.5,Business and Professions VALUATION
- PERMIT ISSUANCE 6,00 SIFT.
,A r Code:Any city owing rea which c.70 1.5,Bs a minest to construct.Professions
Q X 4 o improve,demolish,Or repair any structure,prior 10 its i55nanee,also ELEC.CONTR. LIG NO.
ELEC. /
i S O o requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO � 0: 7
w$m he is licensed pursuant to the provisions of the Contractor's License
Axa
Law(Chapter
9(commencing with Section 7000)ofDivision 3 of the I{ Ptyy1'e i 'Sa a- yq` 4Arr ,F"' �r;g. « .,� $'s& idr cow V,,4J1 FIWA.i RJG
a x D Business and Professions Code)or that he is exempt therefrom and DTV: PLUMBING PERMIT, -:R 7 s PEE-51
M s- r� the basis for the alleged exemption.Any violation of Section 70315 •f.:' wt,. J9,.�` � r 1e �y1�J.*rewy_ STORIES YPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than rive hundred dollars(S500).):
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00
their Sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended Or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 /�/�
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 4.00 SO.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments an not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-l1NC.40UTLETS 4.00
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.) 1,00 BUILDING USE
prov 1.as ownerose
of sale.). INDUSTRIAL WASTE INTER. 20.00 0 la D 0 Or
t as owner of the property.am exclusively contracting with
licensed contractors to construct the project ISec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL rvo.
and Professions Code:The Contractor's License Law does not apply AS
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 contractor)sl licensed puna l0
the Contractor's License Law. SEWER-SANITARY-STORM EA. 200ft/8.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec BAP, f is
reason WATER HEATER W/VENT 4.00
/ Date owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKF-RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4,00
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(See,3800,Lab.C.). n —_
Policy No. Company �P
❑ Certified copy is hereby furnished.
Z Z ❑ Certified copy is filed with the city inspection division. FIRE SPRINK ENERGY T-24
F O Applicant MISC.- REFER TO ORD. Y Y ❑ IN
H CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE '6.00 FLOOD ZONE A.L.u.c.
LU ? COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This section need not be completed if the pernfit is for one TOTAL Y IN C] Y ❑ IN
U ZO hundred dollars(S 100)or less.) -
I certify that in the Performance of the work for which this per FEE SUMMARY
STV - +' A MECHANICAV PERMIT ri.. " e
LL H and is issued,I shell not employ any;person in any manner w as to s `{ FEE-a i-w{a _.
O W become subject to the Workers*Compensation Laws of California. $''x`s`" ;" "e '- ✓- 7 T - ^v cLi.F
G. Date Applicant' pS-a
} rn NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 4.00 BUILDING �O
2 emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 3,00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10pXDQFM.) 5.00 SEISMIC FEE a-D
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). - HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address H EATI N G U N IT IOV ER 100,000 B.T.U.)7.50 ELECTRIC
I certify 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 PLUMBING
ordinances and state laws relating to building construction, and BOILER-COIvP 13 H.P.Or 100,000 B.T.U.1 4.00
hereby authorise representatives f this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-menti d property(or ins lion purposes.
(We) ag o save, indemnify nd keep harmless the City of MISC.- REFER TO ORD.
Cupert o g t liabilities,judg nts, costs and expenses which PERMIT ISSUANCE rnAleT TAX
may a accrue against id City in consequence Of the 3.00
grant go s erre' MECH.CONT. LIC.NO. MECH, s-
4-I �S TOTAL 4`TOTIIII ,. L??.
Signatur of plicant/Contractor Date -ar'• •v g
OFFICE COPY