6140 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
/ aD, DmG APPLICATION & PERMIT - -
ADDRE�D�^ , ftO,l �CL IP -61 40
..`J 40 BUILDING -'ELECTRICAL-PLUMBING-MECHANICAL '
OwNER'S - - PLAN CHECK VALIDATION
NAME . (�� '
W�''� / •T Z-46��• TY. ELECTRIC PERMIT T FEE
rl f PHONE 73
CONTRACTOR'S -
v NAM ."- ' / UTLETS-SWITCHES-RECEP - 5.00/1;00
M S ✓N��/K L,c.No. 5(x 6 7( LIGHTING FIXTURES 5.00/1,00'
CONTRACTOR'S APPLIANCES-RESIDENTIAL ' , 4.00
AODPE55
,
LU7,t' trlU, PHorvE 3� '30S PANELS 5.00 DATE FAPPLICATION
ORRCH,iELT SIGNS J 6.00 PLAN CH KFEE P.C.NO.
E NGINEEll.' • LIC.NO. SIGNS TRANS. 3.00
.. nuoRESS ENG - - SPECIAL CIRCUIT 5.00 : PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 15.00
APPLICANTS
mDRCSx - MOTORS "' - - SEE FEE SCH.
*. 3 SERVICE CHANGE 1000 I'rJ
..1ca 0 0 'LICENSED CONTRACTORS DECLARATION
Q U hereby alirm that I am licenser)under provisi6 sof Chapter - ISSUANCE DATE.'
H G m (commencing with Section 7000)of Division 3 of the Business andProfi, -BLDG. ELECT: 'PICA - MECH.
o" Licensiamese Class
Cod• nlypy licensers in full fir 4, f([LL•C V ❑ ,•❑ ❑
i o License Classes Lice NumM1er Obr -
oTo r w -, Date__Fp/-�, j-�Contract... �yH�
a a f • BUILDING RMIT
¢ ¢ a OWNER-BUILDER DECLARATION -
o d o - INFORMATION
'w 3, LL r .I herehy;afftrnn that I am exempt from the Contractors Luensf L MISC - REFER TO ORD
ton O< Law for the following reason.(Sec 7031.5,Busnnessand Prolessnons r PERMIT ISSUANCE - .. 6.00' VALUATION"• $/FT."
Code:Any city or,county which requires a permit to construct,alter;
¢ ¢ ¢FO innprove,Demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. ..' LIC.NO.. ELEC.
DLL requires the applicant for such permit to file a signed informal th'vl _ TOTAL PERMIT TO
K
m m he is licensed pursuant to the provisions of the Contractor's License'
Fz >' Law(Chapter 9team nscocingwith Section 7000).11ONision 3 of the
Business and Professions Code)or that lie is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢ F m tine basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a3 _. by any applicant for permit subjects applicant toacivil penalty • ALTER-DRAIN&,VENT-WATER (EA.) 4.00
of nm more than five hundred dollars(5500)):
❑ i,as"owner of the property,or my employees with wages as BACK FLOW PROTECT:DEVICE 1 2.00 OCC.GROUP RES.UNITS
J sole compensation,will do the work,and the strutu
cre is net
'intended or offered 1'or sal.(Sec. 7044,.Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
;Code.:file Contractor's License Law does not apply to an owner of
properly who builds or Improves(lemon,and who does such work FIXTURES-PER TRAP 4.00 - SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-.
mems are not intended or offered for sale.If,however,the building, GAS'-EA.SYSTEM-I1NC.40UTLETS 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 he did not build or inl'
. prove for purpose ofsale.). INDUSTRIAL WASTE INTER. Y000 RES ,. IND CON PB Omar
0, L'ae owner of the properly,ani exclusively e n ole ing with ,❑ ❑ ❑ ,❑ ❑'
licensed commetors to ematnmt the project(See.7044,Business LAWN SPRINKLERS'-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License Law does not apply - - ,
to an owner of property who builds or improves thereon,anti who LAWN SPRINKLERS-,OVER 5 (EA.) 1.00 ,
contracts for such projects with a enntractons)licensed pursuant to '
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ •l um exempt under Sec. ',BAP.C.fir this . WATER HEATER W/VENT 4.00 .
reason
Owner Date- WATER SYSTEM - 4.00 _q0_46 ACC.DATE ACC.FILE NO.
WORKER$'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00 , 1.
/ I hereby affirm that I have a certificate of consent to s,Ifiaeu t. - _
1/V�X/\ ur a certificate of Workers'Compensation Insurance,or a certified ZONING - ENG.SITE NO.
copythereof(Sce.3800,Lab.C..)-
I'elicY No. Cnmpnny
• O' ❑ Certified I 'is It Toby furnished. FIRE SPq INK ENERGY T-24
Z 2 AJN Certifie c y ed w' int -i im- _peclioyxdivisian. - MISC.- REFER TO ORD. v N Y N
I- o.. n LKr�ri ❑ ❑ ❑ ❑
CC T PERMIT ISSUANCE 6.00
CIiR'I'I14CA'1'Ii OI°f:XEIONION FROM WORKERS' FLOOD ZONE A.L.U.C.
' 1W > COMPENSATION INSUItANCIi. PL .CONTR. LIC.NO. PLG. tT
.j Z ,(Phis section ne,d not be completed if lhe'permit is for nue V t 3 6`f , TOTAL Q' _ Y❑ IN[j Y ❑ N❑
hundred della,,IS 100)or lc,,.)
U O 1 certify that in the performance of the work for which t
shasis per-to CITY. MECHANICAL PERMIT FEE FEE SUMMARY
U_ H mil is issued,I shall not employ any person in any manner o
.0w becone subject to the Workers'Compensation Lows of California - - -
Datc Applicant a I I ALTER OR ADD TO MECH. 4.00 BUILDING
} m N01'ICIi TO APPLICANT: If,al'Ivr making this Certificate of lix-
F ? ennption,you should become subject to ti,.Workers Compensation APPLIANCE 4.00 PLAN CHECK
provisions of tine Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked: AIR HANDLING UNIT(TO 10=C.F.M.( 3.00
- CONSTRUCTION LEND INC AGENCY -. AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMICFEE
I hereby affirm that them.is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the perfonnunce of the work for which this permit,is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000-B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that 1 have read this application unit state that theabove VENTILATION FAN (SINGLE) 3.00 -
in(nnnation is cortect.1 agree to comply with all city and county - PLUMBING
ordinances and state laws relating to building construction, and 130ILER=COMP(3 H.P.of 100,000 B.T.U.1 4.00
hereby,authariae representatives of this city to enter upon the BOILER-_COMP(0.,100,000 BTU)SEE FEE SCH. MECHANICAL
ahovc mentioned property for inspection purposes.
(We) Tee to rove, indemnify and keep hannless.lbe City of MISC.- REFER TO ORD. -
CaPQP a against liabilities,ja lione ts,.cost.,and c.penses'which - CONST.TAX
may y ay aceru gainVol City in Consequence of the PERMIT ISSUANCE 3.00
ECH.CONT. LIC.NO. MECH.
TOTAL TOTAL D
Signature of Applicant/Contractor Date L"-
<, OFFICE COPY.