13705 (2) r
AP4'LICANT TO FILL IN INFORMATION WITHIN RED LINES — USE LL POINT PEN ONLY
ih .l BUI LDI NG PROJECT!MTI FI N PERMIT NUMBER
aD,Lp,NG APPLICATION & P IT 13705
ADDRESS 3
BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
OWNER'S PLAN CHECK VALIDATION
" ME CITY. ELECTRIC PERMIT FEE
PHONE
Hn"- '•T R*::p �-w�� OUTLETS-SWITCHES-RECEP 10.00/1.00
' LIC.NO, LIGHTING FIXTURES 10.00/1.00
cpNTRAcrons APPLIANCES-RESIDENTIAL 4.00
a O 55
QwrL PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
Llc.NO. ISIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT S.00 PERMIT VALIDATION
a,p TEMP.METER OR POLE INS. 20,00
APPLICANTS MOTORS SEE FEE SCH. pLs�
ADDRESS
SERVICE CHANGE 20.00
. / O// ��7
o o LICENSED CONTRACTORS DECLARATION G
u u 1 hereby affirm (hal 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
z i (commencing with Ian 7000)of Division 3 of t e 8us'ress and
G¢ BLDG. ELECT. PLG. MECH.
F 0 i Prafes,im C n liy�nse is in full fo
Z License Slur '�` (� Lic.Number "� �� ❑ ❑ ❑
Q m r w Date—Contracta
¢ s r BUILDING PERMIT
LD '
¢ I[w OWNER-BUIER DE LA A ON INFORMATION
'n o a. MISC.— REFER TO ORD
w ;LL H I hereby affirm that I nm exempt from the Contractor's License VALUATION SIFT.
H LLoa Law for the following reason.(Sec.703 1.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
2 ¢ < improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
D , requires the applicant for such permit to file a signed statement that TOTAL PERMIT T
K $ he is licensed pursuant to the provisions of the Contractor's License
w z i Law(Chapter 9(commencing with Section 7000)of Division 3ofthe
¢ Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
3 i o
oc H$ lire basis for the alleged exemption.Any violation of Section 703 L5 STORIES TYPE CONSTR.
n ;" by any applicant for a permit subjects the applicant toacivil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,ARENCOND. 5.00
Code:The Contractor's License Law does not apply t0 an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SVSTEM-11NC.40UTLETS 6.00
meats are not intended or offered for sale.If,however,the building
or improvenunt is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) _ 2.00
builder will have the burden of proving that he did not build or int- BUILDING USE
prove for purpose of sale.). IINDUSTRIAL WASTE INTER3000 RES IND CON RB Our.,
CJ Las owner of the property,an exclusively contracting with . .
❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(See. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Low does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with u cuntructory)licensed pursuant in SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ Iamexemotrottr Sec. ,B.&P,C.f.,tlus WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COM PENSAT ION D17CLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Com�pe��f�,Gy�t�m[}/ys me,ora tlfieJ
co1r,Y thereof(Sec.3800,LuM1.C.r "
Policy No. Company
0 ❑ Cc '" copy is her•byl'ur s '— FIRE SPRINK ENERGY T-24
Z 2 ❑ C[ri(ie copy i led ve I city inspection division.
Applical4�( _ip , y MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑ ,
"rs$ CP TIFICATIi O v IiXF-MPTION FROM WORKERS• PERMIT ISSUANCE 10.00 FLOOD ZDNE A.LU.C.
LU — COMPENSATION INSURANCE PLG.CONTR. I.C.NO. PLG. Y[:] N❑ Y [:] N❑
CL Z (This section into not be completed if the permit is for one TOTAL
hundred dollms($100)or less.)
U O I certify that in the performance of Use work for which this per, OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any rerson m y manner so as to .
O W become subject to the Workers' p 1 C 'Dania. 'r- T
y Date Applicant' ALTER OR ADD TO MECH: 5.00 BUILDING
} W NOTICE TO APPLICANT: If,after nw king this Canifirme of Ex-
condition,you should become subject to the Workers'Compensation APPLIANCE 15.00 PLAN CHECK
Provisions Of the Labor Code, you must forthwith comply with
Ur such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10A000-F:M,)R"4.00 FEE
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER.10p000GEM.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITMDUCT) 5.00
re performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
a
Lender's No. -
Lender's Address HEATING UNIT(OV ER 100,000 B.T.U.)9,50 ELECTRIC
I� 1 certify that I have read this application and state that the 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 I3 H.P.or 100,000 B.T.U.) 6.00 ��
hereby authorize representatives of this city to enter upon the BAILER-COMP IOverlW,DoO BTU)SEE FEE SCH. MECHANICAL OE/
above-mentioned property for inspection purposes. •�
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupert 'nliabilities judgments, costs and expenses which PERMIT ISSUANCE 10.00 (] CONST.TAX
may iV��Mnya','
accru ainst said City in consequence of the
gmntienni[ - MECH.CONT. LIC.NO. MECH. ,}ysTOTAL '1 ,K_V TOTAL
Signallicant/Co actor Date �C
OFFICE COPY