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15938 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -: USE BALL POINT PEN ONLY BU LDI NG PROJECT 1 DENT[FI CATION .PERMIT NUMBER BUILDINGAPPLICATION & PERMIT [(� /� Q Ao s1O D BUILDING - ELECTRICAL-PLUMBING-MECHANICAL - � 9 3 8 OWNER'5 - PLAN CHECK VALIDATION " ME MIA4^ STV. "/ , ELECTRIC PERMIT ?-�' FEE; [A4'1 xPMONE CONTRACTOR'S NAME UTLETS-SWITCHES•RECEP 10.00/1.00 Ma LIGHTING FIXTURES 10.00/1.00 ADDRESS tuns Fre X119' APPLIANCES•RESIDENTIAL 4.00 NTRC "It �a Sao PHONE( / f G -t4 PANELS 10.00 SATE OFAPPLICATION ARCHITECT P�,AN,pHC P.C.NO. OR PANELS (OVER 200 AMP) 20.00 AIyA y_ ENGINEER th1le MM LIC.No. SIGNS TRANS. 3.00 S S ADDREENG. Y, ?ERMIT VALIDATION ADD R OR SPECIAL CIRCUIT 5.00 ,-7tYlf pYli gWssa zip TEMP.METER OR POLE INS. 20.00 _ 2 � ADDRESS MOTORS SEE FEE SCH. APPLICANT'S 1�)T yv)p SERVICE CHANGE UORD Woo LICENSED CONTRACTORS DECLARATION <u w' I�hemby afOrm that I am licensed under provisions of Chapter 9 ISSUANCE DATE . w< (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT, PLG. MECH. r n i Professions Code,and my license is in full force and effect. ❑ 131=1❑ oi=D License Class Lic.Number _ Date' ' ' Contractor a sa s � ✓•• •�, - BUILDING PERMIT,,-,?,,A, ¢ ¢w�;• :�,. -.,;, OWNER-BUILDER DECLARATION ,: »t INFORMATION .'ys(3:%i' X o A t- " 1 hereby-. ereby affuiri-that I em exempt from the Contractor's License MISC.-: • - REFER TOu y VALUATION S/FT. no a Law for the following reason.(Sec.7031.5,Business and ProfessionsNJ PERMIT ISSUANCE Code:Any city or manly which requires a permit toconstruct,eller, C cc<cic improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. wo w^ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO -, he is licensed pursuant to the provisions of the Contractor's License i' Law(Che ter 9(commencin with Section 7000 of Division 3 of the �''C2 r`1"t`i o 1 Business and Professions Code)or that he is exempt therefrom and STV. r`y PLUMBING PERMIT Wrrr 4U FEES- ¢ r 8- the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. by any applicant for a permit subjects the applicant ton civil penally ALTER-DRAIN -WATER (EA.15.00 of not more than five hundred dollars(SSGO).): 0-L'as owner of the,property.or my employees with wages as ->, BACK FLOW PROTECT.DEVICE 4.00 OCD.GROUP RES.UNITS theii sole compensation,will do the work,and the structure is not intended or offered for Sale(Sec. 7044, Business and Professions ,r DRAINS-FLOOR,ROOF,AREA,COND- 5.00 Code:The h builds o oLicense Lew does not apply to an owner of property who builds or improves thereon,and who does such work ? FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE -(' menus re through de own employees,provided that such improve- orimprovemenotntissoldoroffered inone year sale. however,the the o ner- GAS•EA.SYSTEM-11NC.4OUTLETS 6.00 r fk, or improvement'is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) - 2.00 BUILDING USE builder will have the burden '.proving that he did not build or im- RES IND CON PS Otbar prove for purpose of sale.). a'.,; ` tr INDUSTRIAL WASTE INTER. 30.00 ❑ El ❑ ❑ 0 - El- 1,es owner of the propeRY.em exclusively contracting with licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. End 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 IEA.) 1.00 - contracts for such projects with a contractons)licensed pursuant to II the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACTNO. PARCEL NO. !. . 0 I am exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 6.00 f reason Owner Date WATER SYSTEM 5.00 ` ACC.DATE ACC FILE NO. WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 1 hereby affirm that 1 have a certificate of consent to self-insure, ZONING ENG.SITE NO. of a certificate of Workers Compensation Insurance,or a certified copy thereof(Sec.3600,Lab.C.). - Policy No. 0Company O Iris Csnlfie oy is hereby furnished: FIRE SPANK ENERGYT 24 Z 2� 71E Cenifie py is filed w' the city inspection division. MISC- REFER TO ORD. O Applicant - Y N Y [3 No ~ PERMIT ISSUANCE 10.00 H - CERTIFICATE OF ' EMPTION FROM WORKERS' FLOODZONE A.L.U.C. SL > _ COMPE ATION INSURANCE PLG.CONTE. LIC.NO. PLG, d C (This section need not be,completed if the permit is for one TOTAL Y IN Y❑ N[3 � Z hundred dollars(S 100)or less.) ^ - U O 1 certify that in the performance of the work for which this per, CITY.'• MECHANICAL PERMIT FEE FEE SUMMARY LL I- mil is issued,I shall not employ any person in any manner so as to become subject to the Workers Compensation Laws or California. i Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING } WNOTICE TO APPLICANT: Ir,after making this Certificate of Ex- F - emption,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK provisions of the Labor Code, you must forthwith comply withFEE U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10.000C.F.NL) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,00011FM.) 6.00 SEISMIC FEE 1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 the 3097 performance of the work far which This permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM v Lender's Name Lender's Address HEATING UNIT(OV ER 100,000 B.T.U.19.50 ELECTRIC I certify that l have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00 -- information u correct.I agree to comply with all city and county PLUMBING ordinances and state s relating to building construction, and BOILER-COMP 13 H.P.or 100,0008.T.U.) 6.00 hereby out r..c re re nlaliyts of city to enter upon the BOILER-COMP lover 100,000 BTU)SEE FEE SCH. MECHANICAL above men ned p p ly fo spe ton purposes. (We) ee to vl. df and keep harmless the Caf MISC.- REFER TO ORD. uperlin ga' B bi i j rights, costs and Zscs..yh' h CONST.TAX ay in y cc r aid City in conscef he PERMIT ISSUANCE 10,00 ranting it., 11 ECHE CONT. LIC.NO. MECH. - TOTAL TOTAL . IaAW S at a pp Icanl o c or- [e OFFICE COPY