5883 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LD1 NG PROJECT I PENT11 FICATION PERMIT NUMBER
BUILDING _6L APPLICATION & PERMIT 5883
AD S
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
PLAN CHECK VALIDATION
NAME ) _ .7;::t.:" .. .y� �+:.
147v C I .ELECTRICPERMIT
/ �V PHONE
CONTRACTOR'S UTLETS-SWITCHES-RECEP 5.00/1.00
(�s NAME �` ) _ ,y
/- S'r& 14r f_A;(,X-.: et%_IC.NO.3 $b LIGHTING FIXTURES 5.00/1.00 AUG
/ CONTRACTOR'S ��. ` APPLIANCES-RESIDENTIAL 4.00 @Dino
ADDRESS
, S' 0k 0-k N 0 sJ/'PHONE J2 7-AP VA PANELS 5.00 pLcivTotp LICATI AN CHECK FEE P.C.NO.
ARCHITECT SIGNS 6.00
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5j,QQ PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
APPLICANT'S MOTORS
ADDRESS SEE FEE SCH.
SERVICE CHANGE 10.00
o o LICENSED CONTRACTORS DECLARATION d
c u u l hereby affirm that 1 am licensed under provisions of Chapter 9D (NA-
(commencing
� �� ISSUANCE DATE
N a a (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
° Professions Code,ed I ense is in full fo e d f ect. t -2 ❑ ❑ ❑
Z o N License Class `_ Lic.Number
° Z - ° Date- Contractor
F_ w
H J
a Y3
a O a v OWNER-BUILDER DECLARATION
MISC.- REFER TO ORD
x 3 w N I hereby affirm that 1 am exempt from the Contractor's License VALUATION
LL o a Law for the following reason.(Sec.703 1.5,Business and Professions PERMIT ISSUANCE 6.00 3�1ON
J Code:Any city or county which requires a permit to construct,alter,
< 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
w ° ¢ requires the applicant for such permit to file a signed statement that TOTAL 1 * � i
PE F
TO
a x $ 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 of the .
a Business and Professions Code)or that he is exempt therefrom and qTY. PLUMBING PERMIT, F
cc I_ °o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES PE CONSTR.
by any applicant for a permit subjects the applicant to civil penalty ALTER DRAIN&VENT 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 GAS-EA.SYSTEM-1 INC.4 OUTLETS 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 im- RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ 1,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. 5.00ASSESSORS 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 r 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.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).Cn. Q
Policy No.. Company )-Vyx)tW ,` cc
C) �ified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certlfie�d�-c,o�py is filedw✓ith the city inspection division. MISC. REFER TO ORD.
O Applicant ( C!�� J��+�`Lp-rd Y Y ❑ N❑ Y ❑ N❑
0: N CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y[:] N❑ Y❑ N❑
d 0 (This section need not be completed if the permit is for one TOTAL
D Z hundred dollars($100)or less.)
V O I certify that in the performance of the work for which this per- QTMy MV MECHANICAL PERMIT FEE FEE SUM ,RY '
LL F- mit is issued,I shall not employ any person in any manner so as to
V become subject to the Workers'Compensation Laws of California.
LU Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
>- t» NOTICE TO APPLICANT: If,after making this Certificate of Ex-
Z_ einption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
C) such provisions or this permit shall be deemed revoked. I AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.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
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.117.50 ELECTRIC
I certify that I have read this application and state that the above V ENTI LATION FAN (SINGLE) 3.00
information is correct.1 agree to comply with all city and county BOILER COMP 13 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 BOILER-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.
C o st liabilities,j osts and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any w accrue nst said C t in consequence of the
granting of this ermit. _ MECH.CONT. LIC.NO. MECH. �O
l !f 1 TOTAL TOTAL -i
l of plicant/C for Date
OFFICE COPY