5850 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT ADOg�SS
(�I/Z � `y�,. BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 5850
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OWNER'S / : PLAN CHECK VALIDATION
`ftldJgX. _ ELECTRIC PERMIT F.E
PHONE
CONTRACTORS OUTLETS-SWITCHES-RECEP 5.00/1.00
LIC.NO. 7 LIGHTING FIXTURES 5.00/1.00
r_o TRACTOR'S �•�
RESS PPLIANCES-RESIDENTIAL 4.00
A �J
k0 r5 PHONE /0 PANELS 5.00 DATE OF APPLICATION
'AAORRCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 55,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANT'S MOTORS SEE FEE SCH, //�-
ADDRESS (I✓ �}
^ SERVICE CHANGE 10.00 //
Ir o LICENSED CONTRACTORS DECLARATION /✓ L ! ' �f
WLi I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
N
Z4' BLDG. ELECT. PLG. MECH.
wa (commencing with Section 7000)of Division 3 of the Business and
r z Professions Cod nd cense is in full for a d f ct (// a e ❑ ❑ ❑ ❑
Z o 11
a - License Class Lic.Number
T - Contractor U- O F A- p n P n e C q r S S
a YBUILDING PERMi
¢ a OWNER-BUILDER DECLARATION / N , a A_ u C ( 1 D ,T n
o a v INDRM'ATIt '.' `h
X 3 LL r I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD -
u. o Q Law for the following reason.(Sec.703 1.5,Business andProfessions PERMIT ISSUANCE 6.00 N /FT.
v, CD
i 2 Code:Any city or county which requires a permit to construct,alter,
¢ ¢ Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
o a o ¢ requires the applicant for such permit to file a signed statement that TOTAL
Ix m he is licensed pursuant to the provisions of the Contractor's License P O
~ Z i Law(Chapter 9(commencing with Section 7000)of Division 3 of the 6111-y
= o Business and Professions Code)or that he is exempt therefrom and QTV, PLUMBING PERMIT FEE
Cc r o the basis for the alleged exemption.Any violation of Section 7031.5 9TOWUPUffifflo TYPE CONSTR.
a 3 by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN WATER (EA.) 4.00
of not more than five hundred dollars($500).):
❑ 1,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 an owner of
property who builds or improves thereon,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-
ments are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4(EA) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- . .
RES IND CON PB Ocher
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ El El❑ 1,as owner of the property,am exclusively contracting with 1:1 El
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The 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 projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec. B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP- 4.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O O Ce led cop 's hereby f rnished. FIRE SPRINK ENERGY T-24
z Z ❑ ertifie_d filed Ith the city:,n)s e ion division.
O Appli ant MISC.- REFER TO ORD. v N❑ v ❑ NE
~ v� PERMIT ISSUANCE 6.00
- CERTIFICATE OF EXEMP M WORKERS' FLOOD ZONE A.L.U.C.
Lu J COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
Z (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y N
hundred dollars(S 100)or less.)
V O 1 certify that in the performance of the work for which this per- PEE$
U_ {- mit is issued,I shall not employ any person in any manner so as to QI MECHANICAL PERMIT FE1=`
V become subject to the Workers'Compensation Laws of California. BUILDING
O a Date Applicant ALTER OR ADD TO MECH. 4.00
} in NOTICE TO APPLICANT: If,after making this Certificate of Ex-
Z_ emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F-M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=1C.F.M.) 5.00 SEISMIC FEE
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
I 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 BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOI LER-COMP (Over 100,000 BTU)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.
LC no st liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any' w accrue s sa ty in consequence of the
grand ermit MECH.CONT. LIC.NO. MECH.
p--?__? � TOTAL TOTAL. S--
ure of Applican Date CJ
OFFICE COPY