8363 (2) APPLICANT TO FILL.IN INFORMATION WITHIN RED LINES= USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION' - - " ` - PERMITNUMBER
9UILDI .APPLICATION & PERMIT
aoD '
%,j p" mD(QO � .,u)' BUILDING-.ELECTRICAL-PLUMBING-MECHANICALJ 8363
OWNER's - PLAN CHECK VALIDATION
NAM �// �', V 6TV. 'ELECTRIC PERMIT •FEE
G'GQ.J PHONE _ ..
.' COA NT CTOR'S
N {{ (p OUTLETS-SWITCHES-RECEP '10.00/1.00
r uc.1RS r�� LIGHTING FIXTURES _ 10.00/1.00
rorvTRAcroR's - APPLIANCES=RESIDENTIAL 4.00 -
1. (/y/[(L'J PHO. si,7 00b PANELS X i M S DATE OF APPLICATION
cmT cT - PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0.
OR
• ENGINEER
uc.NO. SIGNS TRANS. 3.00
ADDRESS ENG SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. .20.00 '
APPLICANT'S MOTORS /•R S
ADDRESS
C . SEE FEE SCH. sSa'
• SERVICEHANGE' 20.00
w o O. LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 -
a Z w I hereby affirm that 1 am licensed under provisions of Chapter,9 - '(A,+ IS A GATE
y a n (commencing with Section 7000)of Di "on 3 of the Business and BLDG:'- ELECT. PLG. MECH.
- N i Professions Co i ; my license is in f II f p
C i w o License lass + 'Lic.No hIF
rs
Dntc Crnu act
Y APR BUILDING PERMIT
¢ ¢w a OWNER-BUILDER I LARATION S
A O w INFORMATION
w ;LL vHi I hereby affirm thdt Cam exempt-from the Contractor's License MISC:= " C' TO.ORD
•
s- LLOj Law lot the followingieason.(Sec.7031.5,Businessand Professions - PERM IT.ISSUAN x "IB'00'. VALUATION, $/FT.
Code:Any city Or county which requiresa permit to construct,alter,
- -
ac ¢ ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. - ELEC.
O LL requires the applicant for such Permit to file a signed statement that TOTA o PERMIT;
u w m he is licensed pursuant to the provisions of the Contractor License c
F z i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
E 2 o Business and Professions Code),or that he is exempt therefrom andBING PERMIT FEE -
¢ I- r� the basis for tile alleged exemption.Any violation of Secl ion QTY. PLUM
7031.5 - STORIES TYPE CONSTR.
a ; _ by any applicant for a permit subjects the applicant toa 4 vil penalty ALTER-DRAIN&'VENT-WATER (EA.) 5.00
of not more than five hundred dollars(1500).):
Cl I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT..DEVICE' 4.00 OCC.GROUP RES.UNITS
their Sole compensation,will d0 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:.The Contractor's License Law does not apply to an owner of
properly 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- ..
ments are not intended or offered for sale.If,however,the building GAS-EA.SVSTEM-l1NC.40UTLETS 6.00
or improvement is sold within one year o1completion,the owner- GAS-EA:SYSTEM OVER 4 (EA.)* 2.00 BUILDING USE
builder will have the burden of proving that he did not build or int - . - RES . IND CNG PB Omar
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30,00 ❑ 'ED ' E] I] 11❑ I,as owner of the properly,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply ,
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 contractors)licensed persuantm SEWER-SANITARY-STORM EA.200ft 10.00 1
the Contractor's License Law. / TRACT NO. PARCEL NO.
❑ I am exempt under Sec..,B.&P.C.for this WATER HEATER W/VENT 6.00
nvwn
Owner Date WATER SYSTEM' 5.00 ACC:DATE ACC.FILE NO.
WORK Ii RS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00 '
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Com�nse.)Ion�nswe,ora ficJ
copy thereof(Sec.38 Co iteRYINZ ) ;l t
Policy No. Com pant LZLP
O - O Cetli a copy is hereby furnished.
FIRE SPR INK ENERGY T2
Z 2 Certif- is filed illy the city inspection division.
O Applicant MISC. REFER TO ORD. Y ❑ N❑ �Y ❑ N❑
~ na PERMIT ISSUANCE 10.00
fL - i IFICATE OF EXEMPTION FROM WORKERS'. FLOOOzorvE, A.L.u.c.
W COMPIiNSATION INSURANCIi PLG,CONTR. LIC.NO. PLG.
CL Z IThis,wetion Beed not be completed if the permit is for one TOTAL Y'❑ N❑ Y❑ N❑
hundred dollars IS 100)or less.)
U O I certify that in t he Performance,of the work I'or which this per- DTV.' MECHANICAL PERMIT FEE - FEE.SUMMARV
LLH mit is issued,I shall not employ any person in any manner SD as to
U W become subject to the Workers'Compensation Laws of California.
D. Date-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING'
} W NOTICE'1'0 APPLICANT: If,after making this Certificate of fix-
Z emption,you should become subject to the Workers'Compensatiun APPLIANCE 5.00 PLAN CHECK
U provisions the Labor Code, you nwst forthwith comply with FEE
provisionsSuchthis permm
it shall he demised revoked. h AIR HANDLING UNIT(TO'10=C.F.M.) 4.00
'CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IOAOOC.RM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency lot EXHAUST HOOD(WITH'DUCT) - 5.00
the performance of the work for which this permit is issued(Sec. - MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 '
Lender's Name H EATI NG UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information n correct I agree t0 g to b with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and slate laws relating to building l city nd co and
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP IDVBr 100,000 BTU)SEE FEE BCH. MECHANICAL
(W , ree to save, indemnify and keep harmless rise City of MISC.- "y - REFER TO ORD.
Cape in against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in try way aceto against said City in consequence of the
[g,at ' 1`this permit MECH.CONT. LIC.NO. MECH.
Cess •J GicucU c3'�S TOTAL TOTAL
[Sigpilture,of Applicant Contractor Date '
' - OFFICE-COPY - -