C8799 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
"�'A ADDRESS10900
Q �x_ _ L FE 8799
'c.!'Yw) BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
---j- OWNER'S PLAN CHECK VALIDATION
NAM �fL C /yyDTV. ELECTRIC PERMIT FEE
1� C01 Vl ?A&W';PHONE 2.5 -1
WO
NAAMERAcrons UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO, LIGHTING FIXTURES 10.00/1.00
ADDRESS
DPPLIANCES-RESIDENTIAL 4.00
CON TRACTOR
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.007777
LAN CHECK FEE P.C.NO.
OR
ENGINEER
Llc.NO. SIGNS TRANS. 3.00
Too its E "G SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
¢ U u I hereby affirn that 1 am licensed under provisions of Chapter 9 . ISSUANCE DATE
G w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
D i Professions Code,and my license is in full force and effect F] ❑ ❑
Z o� - License ClassLie.Number
f W Uaw Contractor
a u s BUILDING PERMIT
¢ ¢w¢ OWNER-BUILDER DECLARATION I AT
oa " MISC.- REFER TO ORD "'
E
w I hereby a(finn that 1 am exempt from the Contractor's License ALUA N S/FT.
H LL o a Lawlor the following reason.(Sec.703 1.5,Business and Professions PERMIT ISSUANCE 10.001N, J11'/
Code:Anycity orcounty whichrequiresapermit loconstmet,alter, /W rE
Qa Q 0 improve,demolish,or repair any Structure',prior to Its Issuance,also ELEC.CONTE. LIC.NO. ELEG Irl•I I'O
O ¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
u w m LL he is licensed pursuant to the provisions of the Contractor's License
r Z i
Law(Chapter 9(commencing with Section 7000)of Division 3 oft he �C/�f 0(-.y d�
a Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
fio
¢ H by basis for the alleged emit subjects
Any violation of Section malty STORIES TYPE CONSTR.
by any more
five permit subjects $500).licanuoacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not marc than five hundred dollars(my em:
❑ Las owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
(S
their wee compensation,will the work,and the sticture not
intended or offered for sale(Sec. 7044, Rosiness and Professions
ions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Cole The Contractor's License Law does not apply to an owner of
himselfy who builds Or improves employees,
proved who doessuchimprove-
ments h work FIXTURES-PER TRAP S.DD SO.FT.FLOOR AREA TOTAL ACREAGE
himself re of rote his own employees,provided ev such
orimprremtinicndcdor withinion yearSale.of
lcompleveq the the o ner- GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of Completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not buil)or im- BUILDING USE
prove fors owner of sale.). INDUSTRIALWASTE INTER. 30.00 EES IND CON Pa ower
❑ d as owner rs the property,ani project
contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors od to construct the Priced(La 7044,Business LAWN SPRINKLERS-1 INC 6 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to antr owner of property who builds t improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
cautions far s 'h prmjccis wiW co tract oil s)liven ud pursuant to
We Contract License Luw. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL No.
❑ I am msi u Er sec. ,li.&I'. .for f is WATER HEATER W/VENT 6.00
reason 1-7
- Owner Dm WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORK H RS'COM PENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 h -by affirm that I have a certificate of conscut to Nelf-insure, ZONING ENG.SITE NO.
or a Certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800.Lab.CJ.
Polity No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z. ❑ Certified copy is filed with the city inspoclimn division.
O Applicant MISC.- REFER TO ORD. Y ❑ N❑ v ❑ N❑
~ vs
LU CERTIFICATE 017 PROMWORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE., A.L.U.C.
> EXEMPTION TIN INSURANCE
W _ COMPENSATION Ptc.CONTE. LIC.NO. PLG.
CL O ('Phis section Tied not be completed if she permil is for one TOTAL Y❑ N❑ Y ❑ N❑
Z) Z hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this Per. DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL P mil is issued,I shall not employ any person in any manner m as to
U become subject to the Workers'Com enation Laws of California.
0 w Date ) A licant p BUILDING
a Pn ALTER OR ADD TO MECH. 5.00
} N NOTICE TO APPLICANT: If,offer making this Certificate of fix.
F ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 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 10MOC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued i5ea MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Adds
1 Certify thresat I have read this application and scam that the above VENTILATION FAN (SINGLE) 4.00
information is correct.I agree to comply with all city and county BOILER-COMPI3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,0008TU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupartin against liJ. dgrocals. costs and expenses which CONST.TAX
y i ny way y in consequence of the PERMIT ISSUANCE 10.00
rand of this pr MECH.CONT. LIC.NO. MECH,
TOTAL TOTAL //] 42.
orale of Applicant/Contractor
Date
OFFICE COPY