3780 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
AD?Fq
D?Fq
1 ' BUILDING—ELECTRICAL—PLUMBING—MECHANICAL �
OWNER'S /-x
N /l/ u.PLANC ECK VALIDATION
ELECTRIC PERMIT FE
NFNT TOas OUTLETS-SWITCHES-RECEP 5.00/1.00
r
LIC,No. LIGHTING FIXT .00/1.00
CONTRACTOR'S PP.LIANC -RESIDENTIAL 4.00 L 1
DPANEL OO DATE OF APPLICATION
ORRCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.N0.
ENGINEER
LIC.No. SIGNS ANS.
ARCR.OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CU IT 5.00
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANT S - MOTORS SEE FEE SCH.
ADDReec�� .
SERVI ECHANGE 10.00 ' � / f
. Woo LICENSED CONTRACTORS DECLARATION 1/
av I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
Us
y a y (commencing with Section 7000)of Division 3 of the Business and ii-al bl"i BLDG. ELECT. I PLG. MECH.
r D i Professions Co�je�ant icense is in full f li g Pqd
oz=W License Class_(„ Lic.Numbe - 0— ElE
y Dale Contractor -
a w 0 O NEi R-BUILUIiR UECL
ew BUILDING PERMIT
A o> u INFORMATION
X a- r I hereby collo that I so exempt from Ilse Contractor'sfessio s _ MISC.— REFER O RD
F LL o¢ Law fertile following reason.(Sec.703 L5,ermit to andcon Professions pERMIT ISSUANCE
Code:Any city or county which requires a permit to constant,alter,
rt2 4 p improve,demolish,or repair any strut Nre,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
a wm, requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
y he is licensed pursuant to the provisions ol'the Contractor's License
ri> Law(Chapter 9(commeneingwith Section 7000)ofDivision 3 oflhe
a Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
ic .$ the basis for the alleged exemption.Any violation of Section 7031.5 1 STORIES T CONSTR.
TSS by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00 1
of not more than five hundred dollms(5500).) I
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECTDEVICE 200 OCC.GROUP RES.UNITS
sole compensation,will do the work,and the structure is not . .
,
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code:The Contractors License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO,FT FLOOR AREA TOTALACREAGE
_ himself re f intended
his own employees,provided what such improve- C^
mentearenotIntended or within
one yearl o l completion,
the theo owner-
GAS-EA.SYSTEM-1INC.4OUTLETS 4,00 OxX
or 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 of proving that he did not build or im-
'rove for purpose ofsale.). INDUSTRIAL WASTE INTER. 2000 REs IND CON PB Omer
❑ I,as owner of the property,am exclusively'contracting with .
licensed contractors to construct the project(Sec 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 500 ASSESSORS PARCEL NO.,
and Professions Code:The Contfuctor's License Law does not apply .
t0 an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a conuactods)licensed pursuant to
the Contractor's License Law. , SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec.—.B.&P.C.for this - WATER HEATER W/VENT 4,00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE,NO.
WORK E RS'COMPENSATION DECLARATION WATER TREATING EQUIP, 4.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO,
ora certificate of Workers'Compensation insurance,or a certified
.copy thereof(Sec.3800,Lab.C.).
Policy No. Company -
O ❑,2£rtilied copy is hereby fur shed.
Z 2 ? Cetl ifie co Iled�l city inspection comm. FIRESPRINK ENERGY T 24
O Applicant._ . MISC.- REFER TO ORD. Y [:] N Y [] N�
CC CF-IIIFICATE OF EXEM PTION 1:RUM WORK ERS' PERMIT ISSUANCE 6.00
FLOOD zorvE A.L.u.c.
LL > COMPENSATION INSURANCE PLG.CONTR, LIC.No. PLG.
CL aZ (This section need not be completed if the permit is for one TOTAL Y D N Y C] `N❑
hundred dollars(5100)or less.)
V O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mil is issued,1 shall not employ any person in any manner so as to
O become subject to the Workers'Compensation Laws of California.
Date Applicant BUILDING
GO ALTER OR ADD TO MECH. 4.00
} m NOTICE TO APPLICANT': II,after making this Certificate sa Ex-
2 empision you should become subject to the Workers Ccomply wit APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000 C.F.M.) 3.00
CONSTRUCTION LENDING AG17NCY AIR HANDLING UNIT(OVER 10=C.EM.) 5.00 SEISMIC FEE v
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). - 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
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction. and BOILER-COMP(3H.P.or 100,000B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree to.save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Caper tin against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in ny ay ' true against said City in conseyuence of the
granting f t r i(L� �//� 4.3/.�j fffJJJ MECH.CONT. LIC.NO. MECH.
_n 0L/�-IW�J TOTAL TOTAL
Signatuf�of ApplicantlContraclor Uatc
OFFICE COP`( '