6296 (2) -APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT P*ON4Y
a BUI LDI NO PROJECT I DE TI FICATION' - '+` .~ PERMIT NUMBER r
BUILDING, . APPLICATION & PERMIT
6296.^ ^
ICAL=PLUMBING-MECHANICAL
B vacs bG b
BUILDING-ELECTR '
awNER's- - PLAN CHECK VALIDATION '
NAME ''
DTV. ELECTRIC PERMIT FEE '
L6�' CeoKr ' PHDNE 2
NOMEnncron's ' • f L' 7Q. UTLETS-SWITCHES-RECEP 5.00/1.00 /
�jJ✓ - .sea 6 Z LIGHTINGFIXTURES 5.00/1.00
CONTRACTOR'S c6 •..� APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE -" c�Z .._.PANELS ' 5.00 DATE OF APPLICATION
ARCHITECT - PLAN CHECK FEE P.C.NO.
OR SIGNS 6.00
ENGINEER
LIC.No.. SIGNSTRANS.' " 3.00
ARCH ENG. �• PERMIT V ATION
ADDRESS CH - - SPECIALCIRCUIT '5.00
ZIP i- - EMP.METER.OR POLE INS. 15.00
APPLIT
CANS_ `- MOTORS . SEE FEE SCH.
ADDRESS
6 COLA il I5 Tam '. -=SERVICE CHANGE-'
wO LICENSEE)CONTRALTO 5 DIiCLARATION;. r ,
ai I hereby affirm Alai I am licensed under provisions of-Chapter 9 A ISS CE DATE
w
a w (comostneing with Section 7000)of Division 3 of the Business and b BLDG. L CT -PLG MECH.
H.N i Professions Code��v���',,,,,,ayyyyyyl y license rs m full fo ct _
z o w- Lmcnsc Cl+ss �qr Lic Number `�Y rEl
0,
GO r w Date Contractor 1. .. -
0 i D
OWNER-BUILDER R.BUILDI.R DCCLAR ON•c t ��. - B-INFORMATION IT
F
g -I- I hereby affirm that'l.am exempt from the Contractor's License` MISC.-v REFER TO ORD - VALUATION SIFT.
I-.LL m . Law for the fogowiog reason.(Sec.7031.5,Businessand Professions pERMIT ISSUANCE .6.00
,A> Code:Any city or county which requires permit to construct,alter, -
2 6 < improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
w ¢ requires the applicant for Stich permit lD file a signed Statement that 0/'r r'�-G•�l]Imo.-.-�� TOTAL �O PERMIT TO
.m he is licensed pursuant to the provisions of the Contmcm}s License "Y T�'G l�-1
fz> Law(Chapter 9(commencingwith Section70000 of Division 3 of On {
F.i o Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT
M I- the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by anyapplicant]or a permit subjects the applicant toacivil penally ALTER-DRAIN -WATER (EA.) 4.00
of not mom than five hundred dollars(5500).):
0 I,as owner of the property,,or my crop[,) with wages m BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP REB.UNITS
Side compensation,will do.the work,and the structure isnot
.intended or offered for sale(Sec. 7044, Business and Professions DRAINS_FLOOR,ROOF,AREA,COND. 4.00
Code: I'he'Contractors License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00sa FT.PLODR AREA TOTAL ACREAGE
• himself or through his own employees.provided that such inmrove- _
mems a re not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-111NC.4OUTLETS 4.00
nr improvement is Sold within one year of Completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
-
builder will have the burden nfpmving.ilia(he did not build or in
prove for purpose of Sale.). - INDUSTRIAL WASTE INTER. 20.00 RES IND C PB Other
0 I,as owner of the Property,am exclusively contracting witll 13 Q. 11:1
licensed CnnImCt0M to construct the project(Sec. 7044;Business LAWN SPRINKLERS+'1'INC 5 V.B. 5.00 - .ASSESS S RCEI.NO.
and 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(EA.) 1.00
contracts for Such projects with a Comraetor(s)licensed pursuant to - - -
theContractor'sLicenseLaw. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. . PARCELNO.
0 I am exempt under Sec. '7B,&1'.C.for this WATER'HEATER W/VENT' 4,00
�1.1 reason '
'f5
Owner Dam WATER SYSTEM 4.00
ACC.DATE ACC.FILE NO:
WORKERS'COMPFNSA1'ION DECLARAt'[ON WATER TREATING EQUIP, 4.00
I'V` Creh
afford
"'allhavc acetlilicatc ofconsent to cell-insure, ZONING
or a c ' bate of Workers'fompenwlion Insurance,ar a certified ENG.SITE NO.
Llpy 111,
it '(Se 3800 Lab.C,-i - ' _
I rfcy N t Compan N• - '
0 0 Cull lied Lrpy is lmrehy_lurnlxlred. ." FIRE SPRINK ENERGYT-24'
Z Z Ce t 0e op
Ix fl w�1 /11�m1 Ira a lion division.
p rC pTiulnl��y:So'� i�r -=T'Q MISC.- - REFER TO ORD. YE] NF] y ❑ N❑
CCR1I FIC T OF IFROM -WORKERS' PERMIT ISSUANCE 6.00
W > COMPFNSAION INSURANCE , FLOOD ZOrvE A.L.u.C.
-
., � PLG.DONTfl. LIC.NO. PLG. -
CL CI( Phis section need not be completed if the permit is for ane TOTAL Y❑ N❑ V❑ N❑
hundred dollars IS 100)or I,,,G)
0 O 1 certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
- 0 w become suhjecl to the Workers Comperisal ion Lows of Calll'orme.
a Date Applicant ALTER OR ADD TO MECH. 4.00 'BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
? emption,ymt should become Subject to the Workers'Compensation APPLIANCE - - 4.00 PLAN CHECK -
provisions of the Labor Code, you must,forthwinl comply with FEE
such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGIiNCY' AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00 '
the performance of,the work for whichthispermit is issued(Sec. - ,MICROFILM
3097,Civ.(:.): HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name - HEATING UNIT 100,000_B_.T.U.)7.50 - 'ELECTRIC
Lender's Address r
w 1 certify that I have read thisapplication and state that the above VENTILATION FAN (SINGLE) 3.00 ,
. inl'onnm1011 is ccRmct. I agrcc.to comply with all city and coanly PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Dr 100,000B.T.U.) 4.00
here
abby auove-mentioned property for inspection purposes.tllnrue representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) a rBe to save, indemnify,and keep harmless the City of MISC.- - REFER TO ORD.
Caper' against liabilities,judgments, costs and expenses which - - - CONST.TAX
ma n ny way accrue a in Said City in consequence of the PERMIT ISSUANCE - 3.00
nti oflihs rmiL MECH.CONT. LIC.NO. MECH.
t D12 - TOTAL TOTAL
S' nature ul' pplicant o raclor ale
OFFICE COPY