13571 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
` BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
EIUH_AODGr55 APPLICATION & PERMIT
�3� .4n1 �r (j W, BUILDING - ELECTRICAL-PLUMBING -MECHANICAL 135 1
OWNER'S 1_1 PLAN CHECK VALIDATION
"P:1 n, QTY. ELECTRIC PERMIT FEE
a ' f'fr orvE
yff
CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
Amw wAL sec.No+W" LIGHTING FIXTURES 10.00/1.00
C,DNTflBCTofl's �u - f A 1� APPLIANCES-RESIDENTIAL 4.00
A41 ►�' 3+ ONEZ-0- W' PANELS 10.06 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMPI 26,66 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
sec.No. SIGNS TRANS. 3.00
ARC H.RENG. SPECIAL CIRCUIT 5,66 PERMIT-'VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00
ADDDRESSDRESSI -
Ars MOTORS SEE FEE SCH, ll /
SERVICE CHANGE 20.00 Ail,
it r
Doo LICENSED CONTRACTORS DECLARATION SS ANCE DATE
a u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
¢ a (commencing with Section 7000)Of Division 3 9f the Business and - BLDG. ELECT. PLG. EC
H h i Professions Code,,*Zly license is in On furcr 9d6gfiANO�_ ❑ ❑
z 0 w- License C Lic.Number_
9 r Date ._LO-1Q'2-Contmctor_Main
a u f �/f/ fBUILDIN PERMIT
a ¢ OWNER-BUILDER DECLARATION
E: ow ca INFORMATION
X ; y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u o va Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION SIFT.
'- -0 Code:Any cityorcounly which requires a permit to construct,alter,
an Q Q Improve,demolish,or repair any Structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
D LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
E
$ he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000)of Division 3ofthc
¢ Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
f z 0
a I_$ the basis for the alleged exemption.Any violation of Section 7031.5 STORI s TYPE CONSTR.
a by any applicant fora permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and I'rol'essions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
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 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-11NC.40UTLETS 6.00
mems are not intended or offered for sale.If,however,Ore building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2,00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose Glide.). - INDUSTRIAL WASTE INTER. 30.00 RES IND CON Pe Omer,
❑ I,us owner of the property,am exc ID,Nely contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(See. 7044,Ifuslness LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The C'ontractor's License Law does not apply
to an owner of property who builds or improves thereon,and.]to LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ l am exempt under Sec.-,B.&P.C.for(his WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.GATE ACC,FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compens surance,o�certified
copy(�WY.o(1 ILIA+
Polic mpuny ���•
0 ❑ Certified copy i. herchy famished. FIRE SPRINK ENERGY T-24
Z ZO �licantCeif"• copy is d with the city inspection division. MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ No
CC y CER1 FICATEOP EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W 1 COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL Z CI (This section need not be completed if the permit is for one TOTAL Y E] N❑ Y C:] N❑
hundred dollars(S 100)orless.)
U O 1 certify that in the performance of the work Ior.which this per- OTY, MECHANICAL PERMIT FEE FEE SUMMARY
IL I- mit is issued,I shall not employ any person in any nhanner so as to
O W become subject to the Workers'Compensation Laws of California. BUILDING
y Date Applicant ALTER OR ADD TO MECH. 5.00
} to NOTICE 1'0 APPLICANT: If,after making this Certificate of E.
F Z eruption,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„) such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10ACC.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the 3097cCiv.C.jnce of the work For which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
,
Lender's Name HEATINGUN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
1 certify that I have read this application and state that(he above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP I3H.P.of 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOI LER-COMP IOver 100,000 BTUI BEE FEE CH, -MECHANICAL
St
above-mentioned property for inspection purposes. l
(We) agree to save, indemnify and keep harmless the City of MISC.- 01 7.7Z7012 ER TO ORD.
Cuper lino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue,against said City coli equence of the
gran' of this pe L MECH.CONT. LIC.NO. MECH.•
TOTAL
Signa re oI Appl cant/ m actor Date ,3 TOTAL 3 �'
OFFICE COPY