2259 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONYfN
13UI LOT NG PROJECT I DENTI FICATION UMBER
0ILDING APPLICATION & PERMIT PE 2259
ADDRESS BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
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w I,— I [] PLAN CHECK VALIDATION
T NN/AyyM1�E /(' fALCO f'�r OTY. ELECTRIC PERMIT FEE
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CONTRACTORS UTLETS-SWITCHES-RECEP 5.00/1.00
NAME Xp f
�(^' VWL V L Tic.no, J LIGHTING FIXTURES 5.00/1.00
XroerRAcroRs Qaerc ' APPLIANCES-RESIDENTIAL 4,00
AOOREs/s p/y�r1 (�
p���r•t^yuJ e-PNONE y PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE DDRESS SCH. (["L
A /
J- �.L ICE IQ IA, SERVL_ _ 10.00
,02 LICENSED CONTRACTORS ECLARATION9
B
a v U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y Z w (commencing with Section 7000)of Division 3 of the Business andBLDG. I ELECT. 1 PLG. MECH.
r ( Professions Cod icent.and y.lse Is in full force and effect. n1-1 ® ❑ ❑
Z, O m LiJUL z lo !982
cense class Lie.Numb
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F Date Cm,trunor
Q x F
¢ ¢ OWNER-BUILDER DECLARATION BUILDING PERMIT
F. ¢ w ` INFORMATION
U REFER TO ORD
F.
LL H I hereby affirm that 1 am exempt from the Contractor's License MI$D.- VALUATION $/FT. .
F u O J Law for the following reasmr.(Sec]031.5,Business and Plafessions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct.alter,
¢ ¢ improve,demolish,or repair any structure,prior to its issuance,oba ELEC.CONTR. LIC.NO. ELEC. U /
O C requires the applicant for such permit to file a signed statement that TOTAL PERMIT T
wca he is licensed pursuant to lire provisions of the Contractor's License E� /p
Hzi Law(Chuptcr9(commencing with section]000)oCDivision 3ol'Ihe d 1-6-AJ
a Business and Professions Code)or Olaf he is exempt therefroln and OTV. PLUMBING PERMIT FEE
¢ e the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d ; m by any applicant for a permit subjects the applicantoacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollurs(55001.1:
❑ 1,as owner of the properly.or my employees will,wages as BACK F LOW 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 m an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 so.FT PLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided that such insProve-
meats are ..untended or offered for sale.If.however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or an"Itvonient is sold within one year o1completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that Ire did not build or inn" RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the Property,am exclusively contracting with
licensed contractors to construct Ore project(Sec. 7044.Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL No.
and Professions Code:I'he 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 pmjcers with u cuntractortsl licensed punuani ns
the Contractor's License Law. SEWER-SANITARYSTORM EA.200ft/8.00 Tgner No. PARCEL No.
❑ lura exempt m,der Sec. .B.&P.C.for Oris WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSA1ION DE:CLARAI'ION WATER TREATING EQUIP. 4.00
I hereby affirm thus 1 have a certificate III C11011111 to Sell'-insure,
or a certificate of W'orkerd Compensation Insurance,or a certified ZONING ENG.SITE NO.
Copy lh_er' 0.0
lis 11 IY P Puny
0 ❑ Cerlilicd w ry is hereby fc,indud. �q FIRE SPRINK ENERGY T 24
Z Z Certified copy is tiledJ-�,ry"rt�1irr''r the c inspection division. MISC.- REFER TO ORD.
FQ Applicanl�, .- s164G6i Y❑ N� Y � N�
try CERTIFICATE 017EXEMPIION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U,C.
LU > CO..IPENSATION INSURANCE PLG.CONTR. LIC.NO. I.G.P
CL 0 tThis action need not he completed if the penttit is for one TOTAL v[:] N� Y NC]
Z) Z hundred dollars 1$100)or Ic,)
U O 1 certify that in the performance of the work for which itper- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL ♦- mit is issued, I shall not employ any person in any manner sn as m
Ow becoina sub ecl to the Workers'Con,I ensation Laws of Culitixnia. �y
n Dae ) APPIICanI ALTER OR ADD TO MECH. 4.00 BUILDING f0 S`
} ru NOTICE TO APPLICANT: If,after making this Certificate of Ex-
emotion,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
pmvision,s of the Labor Code, You Fund forthwith comply with FEE
U such provisions or this Permit shall be dear¢d revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 3.00
CONS'FRUC'I'ION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000GF.M.) 5.00 SEISMIC FEE s�
1 hereby affirm that there is a co.d,neiion lending agency for EXHAUST HOOD (WITH DUCT) 2.00
tire performance 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(OV ER 100,000 B.T.U.)7.50 ELECTRIC
Lender',Address
I certify that l have read this application and slate that Ole above VENTILATION FAN (SINGLE) 3.00
inionnmion is correct.l I agree di comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
o torroa n and stale laws reading ting to building construction,c, and
hereby uuthorix representatives of this city to enter upon the BOILER-COMP (Over t00,000BTU)SEE FEESCH. MECHANICAL
�./ above-mentioned property for inspection purposes.
(We) agree to save, indmmrify and keep harmless the City LII MISC.- REFER TO ORD.
Slpertimi against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
Ilxy 'n/+/+any,way accrue against said City in Consequence of the
6� of this perau / MECH.CONT. LIC.N0. MECH.
�7 TOTAL TOTAL
SlgoaNre ol'A�nt/Co racto-Zi�
&y, �-^- OFFICE COPY