8184 (2) APPLICANT T.O FILL1N-INF0RMA'I'IUN WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LD ING PROJECT ID TIFICATION PERMIT NUMBER
- APPLICATION & PERMIT
BUILDING
ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 8184
OWNEH'R ' '•r -'.i PLAN CHECK VALIDATION
-
NAME In�E/�. �vC�S.TC.. •� SfVi•v tJ OTVa :i 3� ELECTRIC PERMIT x''�it(R� :r+ "FEEI'ix
'S' •�
PHONE 'xf/ .k r(T ti t'.,F
CONTR TORS UTLETS-SWITCHES-RECEP 10.0011.00
NA ' V V D
Ic. LIGHTING
No. FIXTURES 10.00/1.00
ONT CTOTR's )Ajg' ' PPLIANCES-RESIDENTIAL 4.00
rr..
.� PNONEft I PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.No. SIGNS PECIAL IRCNS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
zlv EMP.METER OR POLE INS. 20.00 n J
APPLICANT's MOTORS SEE FEE SCH.
AO R.A.As'S$
Lill hu lk, _ SERVICE CHANGE 20.00
Woo iU CONTRACTORS ]fiCLARATION TEMP.POLE 30.00
LIIiNSI
a u u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
G a w (commencing with Section 7000)of Division 3 of t'h.e'e�uBr''usiness and BLDG. ELECT. PLG. MECH.
H N i Prnlessions C de,'AFRBUI�LII)ERDF(CLARATION
u is in full for" Iyyl'{'fjlr /-y
z o H License ClauLic.h'umbe /..7 (L ❑ ❑ ❑
9 vi f w Date_ Contmc
r*'?'(,':BUILDING PERMIT',;,4,-r`I�,PawaOW' )'-L'
u o a ° MISC.- REFER TO ORD -"^%',r,x NF,ORMATIONr,`„;i.ryx:';
X ; of I hereby affirm that 1 um exempt from tht Contractor's Li¢ryI¢ VALUATION S/FT.
F ..
04 Law for the following reason.(Sec.703 1.5,Businessund ProfeJ�Gro PERMIT ISSUANCE 10.00
Code:Anycityorcounly which requires a permit to consirusJ'elteq
C Y4 FO. imprnvt,demoliah,or repair any SITHelua,prior to it,is,Vyu e,), ELEC.CONTR. LIC.NO. ELEC.
m LL rcgmrcs the applicant for such,antic 1D life a Signed al Anent fiat TOTAL PERMIT TO
x he D licensed pursuant to the provisions of the Contr IDr s License
Law(Charter 9(commencing will,Section 7000)o rvislon3ofthe - ,3 Ivd;: 1s e MLC.
f z ef Business and Professions Code)or that he Is exe pl then Hom and OTY. _ PLUMBING PERMIT x .�. e.v sFEE.
r m the basis for the alleged exemption.Any viola n of Section 7031.5 :•- Jam-•._,s,vt . u.a�L.v STORIES TYPE CONSTR.
i by any applicant for a proem subjects the a cant to a civil penally ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(ES IJ:
❑ I,as owner of the property,or enployeea wi0t wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP HES.UNITS
their sole compensation,will do the ork,and the strucl are is not
intended or offered for sale (Sec. 044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License aw does nut apply to an owner of
property who builds CH impro >thereon,and who docs such work FIXTURES-PER TRAP 5.00 s0.FT.FLOOR AREA TOTAL ACREAGE
himself or through hlsawn ploys,provided that such improve- GAS'EA.SYSTEM-11NC.40UTLETS 6.00
mems are nm intended or ffereJ for sale.If,howeveq We building
or improvement is sold thin one year of Completion, the owntr
wilder will have the rden of proving that he did not build or ire- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose o- ale.). RES IND CON PB Other
❑ Las owner I'the property,ant exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
licensed cant,. ors to construct the project(Sec.7044,Bushnell LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
a and Proftssio Code:'fhe Contractor's Licenx Luw Joes not apply
to an owne of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contrzns rr x Licenects wish.contractorts)liccnxJ punumtl to SEWER-SANITARY-STORMEA.200ft/10.00 TRACT No. PARCEL NO.
the Co actor's License Luw.
❑ am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
aa. n
O ter U.a WATER SYSTEM 5.00
ACC.DATE ACG FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EOUIP. 5,00
1 hereby affirm did I have a certificate of consent to scll�iniurc, ZONING ENG.SITE NO.
or a certificate of Workers'Come fSa Iion Insuran or a nr ilicd
caftal'
�j}��,�g00,Lvb.C�
PC
Q tlm-(i dpy is hercb' mished. FIRE SPRINK ENERGY T-24
FO it copy ision tie city in, cti.If division. MISC.- REFER TO OR D. Y ❑ N❑ Y ❑ N❑
wPERMIT ISSUANCE 10.00
Cr C f A'f: EX:M1IPT O I DA1 UI E FLOOD 20NE A.L.U.L.
LU _ COMPENSATION IN SU RANCE PLG.CONTR. LIC.NO. PL .
0. Z let
( This Section need not be comped if Dn ie permit for one .! TOTAL Y❑ N❑ Y ❑ N❑
hundred dollars IS 100)or leu! ti. - -;�
V O 1 certdy Wet m the performance of the work for whish IhN phr - v .:FEE SUMMARY
LL y- inn is rs' ed I shell not employ any person in any mann rK.s to OTY. MECHANICAq IT ,FEE,`i
0b L r4_
O become subject to tireWorkers Competontimt Laws of Culyf mum.
i Date Applicant / ALTER DR'ADD TO ME ^1 5,00 BUILDING
} to NOTICE TO AITLICAN'P: If,alter, making of I!x-
Z emption,you should became subject to the Worke Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Lubar Code, you must I'ortl dl, comply with FEE
L..1 such provisions or this pennil shall be deemed voked. AIR HANDLING UNIT(TO 10 Q 4,00
CONSTRUCTION LENDI ,AGENCY AIR HANDLING UNIT GEM.I 6.00 SEISMIC FEE
I hereby affirm INC there is a c struction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
Jle performance
rfo mance of the work for ich this permit is issued(Sec. HEATING UNIT (TO 100,000 B.T.U.) 0.00 MICROFILM
Lender's Name
Lender's Address HEATINGUNIT(OVER 100,000B.T.U.)9.50 ELECTRIC
I certify thatlhave ad Ills application and Staff than thealmne VENTILATION FAN (SINGLE) 4.00
information is core . I .gat to comply with all city mW county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.001PLUMBING
ordinances and le laws relating to building construction, and
'�� creby author a representatives of this city to enter upon the BOILER-COMP IOvn 100,000BTU)SEE FEESCH, MECHANICAL
above-menti ed properly for inspection purposes.
I W ree to s,oc, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Co ,I uagainst l"cylw meets, soars and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may n any W' aceru gai said City in inn •quere of the
gr ting of It prior MECH.CONT. - N MECH.
TDTAL rc� `•TOTAL
Signature of�Spp i. , t unor a1 r •
OIFFiiCE CO