4759 (2) APPLICANT•TO FILL IN,INFORMATION WITHIN RED LINES - LISE-BALL POINT PEN ONLY
BUI LDI SIG P O,WCT I DENTI FICATION .• -, • . PERMIT NUMBER
BOILOING - .. �' APPLICATION & PERMIT _ r�G(�
ADDRESS 1 J J
�. BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNEn - ' PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE A
�� OUTLETS-SWITCHES � `IO
coNtRAcr 's ' SWITCHESRECEP . 5.00/1.00
NAME �y(//1MAU/QGf!" J
LIC,NO LIGHTING FIXTURES 5.00/1.00 O 19e^
IL
CCNTRA eT APPLIANCES,RESIDENTIAL 4.00 �.%t xJ
PANELS 5.00 ' DA'44f1B ICATION
ARCHITECT - SIGNS ,, 6:00 - " PLAN CHECK F P.C.NO.
ORJOS
ENGINEEI - ,
uc.No. SIGNSTRANS. 3.00
ARCH,OR ENG, PERMIT.VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
�` `�� `�•� ZIP EMP:METER OR POLE INS.
ADDRESS - - MOTORS r SEE FEE SCH. \�
SERVICE CHANGE .• 10.00 \
w o: LO LICENSED CONTRACTORS DECLARATION
<u U. I hereby affirm that I am licensed under provisions of Chapter 9 _ ISSUANCE DATE
H G w commencing with Section 7000)of Division 3 of the Business and O ^ y BL .ELECT. PLG. MECH.
•• P onna.,; c, d t license is in full fore u J fec ( 'C
z _License Class Lic.Number V - -
9 z set r c Dot Contractor -
¢ m s � - I BUILDING PERMIT
¢ ¢ w OWNER-BUILDER DECLARATION " INFORMATION
.W ;,y I hereby Ofinn that I um exempt from the Contractor's License MISC.- REFER TO ORD vALUAT
1 eV -
,Lo4 Law for the following reason.(Sec.7031.5;Businessand Protestant' PERMIT ISSUANCE .6-Qp oui
de:Any city or county whichreqresapennit toconst RleL alter, L
FC _
¢ 2 fntprove,dernolish,or repair miy struc tire,prior to its iS Onnee,also ELEC.CONTR. - LIC.NO. ELEG.
¢ mptires the app icani(or such permit to file n signeA xtfnelneI thnl TOTAL
w m a he I,licensed pursuant to the provisions of the Contraeloiv License � PERMIT TO
Fzr - L.w(Chapter 9(commencing with Section 7000)ofDivision 3 of the y/
E 4 0 'Business and Professions Code)or that he is exempt forefrom.ml CITY. - PLUMBING PERMIT FEE .� 1"t/E/ !•
¢.H the bosis for the alleged exemption.Any violation nfSection 7031.5 A STORIES 5
ate _ by unyapplicanl for.permit subjects the upplicum to.civil penalty ALTER-DRAIN -WATER (EA.) 4.00
'
.fact more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 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 Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to.n owner of -
property,whobuildsorimprovesthereon,and who docs such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided thin such iinprove-
menusale Act intended orOffered for saIt.If,however,One handling GAS-EA.SYSTEM-1.I NC.4 OUTLETS 4;00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 •BUILDING USE
builder will have the burden of proving that lie did not build or im-
provefor purpose ofsale.). INDUSTRIAL'WASTE INTER.' - 20.00 - IND CON .PB Omer
�n ❑ I,as owner of the property,am'exchtsively contracting with _ - ❑ ❑ ❑ ❑
licensed contractors to construct the pwiem(Sec. 7044,Business LAWN SPRINKLERS-'I INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
( unit Professions Code:'I'he Cmilmetor'S License Law does nut apply - -
to ani owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 "
�( c
tracts lot Such projects with a contr.ctons)hCePted Purxuant 10 -
L'r_) 'the C....Ha Ors License Law- SEWER-SANITARY-STORM EA.200ft/B.00 TRACTNO, PARCELNO.
1
❑ I um exact t undLr Scu. N k .(.Ib r 11 le
mason
:• i
_ WATER:R EATER W/VENT . 4.00
_ ..
I�r� Did, Owner - WATER SYSTEM - 4.00 ACC.DATE ACC,FILE NO.
1 WORKGRS'COMPENSATION DECLARA'IION WATER TREATING EQUIP. 4.00
IInertly,affirm that l have a certificate of consent to self insure, - ZONING
or a certificate o6 Workers'Compensgi n Ipsuru{ r.certified ENG.SITE NO.-
copythereof(Sec.3900;Lab.CI A7g,1� }'�iqp, - '
Ole No. Company ZUS - a'
Q ❑ Certified copy is hereby furnished. F - FIRE SPRINK ENERGY T24
_z 2 ❑ Certified'
O. Appliy is flet with n cit i cation divwon. MISC!- - EFER TO ORD.
Cun - - 1.RY❑ N.'❑ v ❑ N❑
~ rn - - A.L.u.c.PERMIT ISSUANCE- 6.00 FLOOD ZONE '
CC - -CE RT I P KATE OF 1:XEM PT ION PROM WO R K 1:RS'
LU > _ COMPENSATION INSURANCE , PLG.CONTR. LIC.NO. PLG.
CL �' ('Phis w iidn•need not'be completed i(the punnit is for-one TOTAL - V❑ N❑ v❑ N❑
hundred dollan($1001 orlcsaJ . 4'
U O I cintit, that in the perforntanc,"of the work for which this per OTY. - MECHANICAL PERMIT FEE - FEE SUMMARY
LL 1- Inst is '.0•d, I hall not employ any persmt many In Inn r s an to
U beempe subject w the Workers'Compensation Laws +f C lif unto. - -
y Dd Applicant 'ALTER OR'ADD TO MECH.. 4.00 BUILDING '
} to NO] Cl: 1'O APPLICANT: If,after making this Certlllcnte oh nix- _
F2 en"nion,you should bacomesubjeat,to ilia Workers'Conipmtsation APPLIANCE 4.00 PLAN CHECK ,
provision, of thcd:.bor Code,'you most forthwith comply will, FEE t, _
CJ such provisions or this permit sl,&II he teemed invoked. ' 'AIR HANDLING UNIT ITO 10000 C.F.M.), 3.00
CONSTRUC7lON LENDING AGENCY AIR HANDLING UNITIOVER 10=C.F.M.) 5.00 SEISMIC FEE 1•A
I hereby affirm that there-is a construction lending agency for EXHAUST,HOOD (WITH DUCT) 2.00
the perlitrmance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 - MICROFILM
3097,Civ.C.).
Lender's Name HEATI NG UNIT(OVER 100,000 B.T.U.)7.50 -
Lender's Address ELECTRIC
I certifythat l have read this application an'" "'
then the above VENTILATION FAN (SINGLE) 3.00
infannution is correct. I agree to comply with all city and cmmty' - PLUMBING
ordinances and state laws relating to building constmmion, am! BOILER-COMPI3H.P.or 100,000 B.T.U.) 4.00
hereby autlrorire representatives of this city tti enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposu�n
(We) agree to save, indemnify and'keep hurnnles,v the City ul MISC:- REFER TO ORD. - -
CuperOno against liabilities,judgments, costs and expenses which .. CONST.TAX
• may in any waynettagainst said•City in consequcn<c nl'the PERMIT ISSUANCE 3.00
grxntin of this pennil. > MECH.CONT.' LIC.NO. MECH:
/2- o TOTAL TOTAL
ignaturc nl'APplmnn Corpra or, Dan
• „ '.'i OFFICE COPY - - -