14789 (6) 3�APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUDDING APPLICATION & PERMIT E] (]
ADDRESS r J
f � � %� ��L'✓C{/ �,� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S D w e'r :L.Cel S PLAN CHECK VALIDATION
NAME OTY. ELECTRICPERMIT FEE
;.. j,") ll 'T PN.NE
i
CONTRACTOR
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME //
J PL✓m (3 LIC.NO. y�'b a LIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS '(
4_e/L e_, PNONE2 JPANELS 10.00 DATE OF APPLICATION
ARcnrrecPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
of,
ENGINEER
uc.No. SIGNS TRANS. 3.00
ADDRESS Eric. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH. ;y
a.ORess _
SERVICE CHANGE 20.00 I �l.•4 I� -� -'',- 02 LICGNSIiII CONI'RAC1'ORS UECL\RA'I'IONI
7 }-J
a U I hereby affirm 0u( I and 000)uJ under n 3 ofi.t,of Clwp(er'I ISSUANCE GATE
H <n Iconunenaing w'it11 SCctiou 70001.I Diriaion 3 ul(hc Bu,ine,s unJ BLDG. ELECT, PLG. MECH.
r N i PRd...ions Cod Lid try 6aue is ill(Lill lame and afo,t. (` I'-
0 . -
'- tl� ❑ ❑
z O m License Class J Li,.Number -c'UT'�
O Z rDOta`_ COnfr'JetOr
BUILDING PERMIT
m w u
OWNER-B UILUEk IIECL,\IL\PION
REFER TO ORD INFORMATION
w 3 LL w I heeby all irm thus I am Cxemp( from 0nu Com acme's Licnua• MISC,- VALUATION f/FT.
H ..
04 Law for the following eusi n.(Sec.7031.5,Iiluincvsund Prufnsions PERMIT ISSUANCE 10.00
Code:Any cily ur cuunly which eq uires a permit to c.ns(ruC1,ohm.
R ¢ ¢ improve,demolish,or repair any'stmeture.prior to its issuance,also ELEC CONTR. LIC.NO. ELEC.
G LL requires the applicant for such permit to fila signed st'atanenl[flat TOTAL PERMIT TO
w $ he is licensed pursuant to the pr.via.ro of the Conlouuor's Li.C..ae
I Law(Chapter 9(cummendingwitb Section 7000)of Uivi,.u3 of tile
a Business and Professions Code)or that h,,,cxmnpn demflnm and OTV. PLUMBING PERMIT FEE I rf
r the basis lar the alll,ld exons,Goo.Any violatimh lu Suclioa 7031.5 STORIES TYPE CONSTR.
d ; by any applicant for It permit subjects the applicant 1.acivit penalty ALTER-DRAIN -WATER IEA.) 5.00
of not note Iran five burned dollars(S500).):
❑ I,as owner of the ,,.Perry,or my crrhployce.+with wa,", BACK FLOW PROTECT. DEVICE 4.00
their sole canpensolion,will Jo the work,and the 4mctal ivun OCC.GROUP RES.UNITS
uncoiled or offeed for sate lScc. 7044, Business and Pr.(caiolnDRAINS-FLOOR, ROOF,AREA,COND. 5.00
Code:Thr Contractor,License Low does not apply to an owner o1
properly who builds or inhpruves thceun,and who does such work F IXTUR ES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
himself or Ihro.gh his own employee,,provided that such improve
`;_• meso an not intended or offered for sate.IC however.the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
.r improvement is sold within one year.I completion. Rhe uwnen GAS-EASYSTEM-OVER 4 (EA.) 200 BUILDING USE
builder will have the bonen of proving drift he did not buil)m hLi . . .
- RES IND CON PB Ohher
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,m owner of the property,am exclusively c.ntueting wi Dh ❑ ❑ ❑ ❑ ❑
l cenaed contract.,, to 1.1olloet the p,ojvct(See. 7044, Ibuinc+s LAWN SPRINKLERS- 1 INC 5 V.8. 6.00 ASSESSORS PARCEL NO.
and Professions Code *File Contractor's License Law dues nal 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 contmmu,ls)licensed punuont to SEWER-SANITARY-STORM EA.2001[/10.00
Ilse Contract.,',License Law. TRACT NO. PARCEL NO.
❑ Ian exempt under Sec,-,B,A.P.C.ler the+ WATER HEATER W/VENT 6.00
reason
Owner Ume WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPI:NSA'I'ION'DECLARATION WATER TREATING EQUIP. 5.00
1 hereby uHiou that I have a ccrtificalc Ill consent I.sclGlnsac.
or a certificate of Workers'Compenuat ion Insurance,or a cer(ificd ZONING ENG.SITE NO.
ropy thereof SeW800,500,Lab.C.).
Policy No._ ._RnhquhnY_ _
Q O CertilieJ fy is hereby lu lel d. FIRE SPRINK ENERGY T-24
z 2 O Cetlili :.py is tiled 'n We city iropeCtion i''to'
O Applicant_ _ _ _ MISC. - REFER TO ORD. Y ❑ N❑ v ❑ rv❑
F" w ' ,irm`y/, PERMIT ISSUANCE 10.00 I\
cc Clikl 'I(UJ COMI'I'.INSA!IION IN SU ANCE OIt KI[kS' VLG.CONTR. LIC.NO. PLG. �,. FLOOD ZONE A.L.U.C.
Q. o (Tlhis section need not be completed Ithe penhut i+ fur one TOTAL I-) Y❑ N❑ Y ❑ IN❑
M Z hundred dollar,U 100)or lea.)
U O 1 certify that in the performance of tile work for which Ibis per. CITY] MECHANICAL PERMIT FEE FEE SUMMARY
U. I- mit is issued,I shall nm mn,lcy airy lenun in any Inanner+u ua to
O w baotne subject to the Nbrkeri Compensation Laws.I(olitbrnia.
y Uate Applfeant ALTER OR ADD TO MECH. 5.00 BUILDING
} Dy NOTICE '1'U APPLICAN I': it,after,,raking this Certificate of Fx-
F.. Z anp(iom you should becume xhbjeel In the W.Ikeri Cumpeusatiun APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, You FIRS( forlhwith comply with FEE
V such provisions or this,emit shall be deemed revoked. AIR HANDLING UNIT(TO 10)000OF.M.) 4.00
CONS'I'kUCI'ION LI:NUWC AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a constriction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
Ole ler(imnance oI the work lar which Ibis permit is isued(Sec MICROFILM
3097,Cw.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Nature s HEATI NG UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
I certify 0wt I have read this aPpllCatloo and state That the Above VENTILATION FAN (SINGLE) 4.00 i
information is correct. I agree to comply with all city and county PLUMBING 7
ordlounees and state laws elating to building construction, unJ BOILER-I MP I3 H.P.or 100,000 B.T.U.) 6.00
r.,,,.• harcby olnboriae rcprcentulives ul Thia oily to enter upon Ih4 BOILER-COMP IOver 100,000 BITER SEE FEE SCH. MECHANICAL
abovcmentioned,,.Perry for Ew,,,tion purposes,
IWil ollio to save, inden lily and keep herrnkss (bc C'lty or MISC. - REFER TO ORD.
u p/, /"9ains( liabhli lica!i dgmeat" Cus,, and expenses which CONST.TAX
ay way accrue g' LSI said City in eunuyuaer o('Ou, PERMIT ISSUANCE 10.00
conIII pennil. MECH.CONT. LIC.NO. MECH.
TOTALSignP,licam Cornu. r TOTAL I/•7
OFFICE COPY