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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
5 9 8 3
BUILDING
AD ESS
Ot NtH b
NAME
rRAA) 1< XWAASS.ONE
A
PLAN CHECK VALIDATION
CONTRACTORS
N
OUTLETS - SWITCHES - R ECEP 5.00/1.00
rA) 0 (,4J 6 4 -r -W LIC. NO_3JW0/0/
DATE OF APPLICATION
LIGHTING FIXTURES 5.00/1-00
CONTRACTOR'S
ADDRESS
nf&A Ll HONE
[APPLIANCES - RESIDENTIAL 4.00
PANELS 5.00
ARCHITECT
OR
ENGINEER LIC. NO.
SIGNS 6.00
PLAN CHECK FE7.C.
NO.
SIGNS TRANS. 3.00
ARCH_ OR ENG.
ADDRESS
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
FEMP. METER OR POLE INS. 15.00
"P
APPLICANT'S
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DECLARATION
Me) �_rn b ko!q Was
C?
I hereby affirm that I am licensed under provisions of Chapter 9ISSUANCE
(commencing with Section 7000) of Division 3 of the Business and
P,ofessionsC d d I' se is in full force an
, � T4en -1
,Li 'S'�X Lic.t�u!nber_3_1
Ise C
Date 1E on �'J'Lsw
DATE
BLDG-
El
ELECT. PLG. MECH.
1:1 11 ❑
OWNER -BUILDER DECLARATION
MISC. REFER TO ORD
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 703 1.5, Businessand ProfessionsPERMIT
Code: Any city or county which requires a permit to construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business ness and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5
ISSUANCE 6.001 r
VALUATION $/FT.
_,.,184
ELEC. CONTR. LIC_ NO.
ELEC. V L
TOTAL
PERMIT TO
PLUMBING PERMIT "0
STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars ($500).):
ALTER -DRAIN & VENT -WATER (EA.) 4.00
0 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP RES_ UNITS
C -
I DRAINS -FLOOR, ROOF, AREA. COND. 4.00
IFIXTURES - PER TRAP 4.00
SO_ FT. FLOOR AREA TOTAL ACREAGE
property who builds or improves thereon, and who does such work
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 -
builder will have the burden of proving that he did not build or im-
prove for purpose of sale.).
D 1, as owner of the property, am exclusively contracting with
RES IND CON Pe Other
El Q E] 1:1 1:1
INDUSTRIAL WASTE INTER. 20.00
licensed contractors to construct the project (Sec. 7044, Business
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- I INC 5 V.B. 5.00
ASSESSORS PARCEL NO.
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.
0 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.
WATER TREATING EQUIP. 4.00
WORKERS'COMPENSATION DECLARATION
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 abC- - .:
Lp.). � 7D,,,-/
Policy No. Company
nany '4 ; , .
FIRE SPRINK
Y ❑ N ❑
ENERGY T-24
Y [:] N El
• C * e ' ere urnished.
copy
copy
• Zied �,opy' tion division.
fi i
?�Ve: y ed with the city on.
A I JP)-
pp ty :
_N
_�O
MISC. - REFER TO ORD.
- ��Mwc
C ATE F EXE WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.U.C.
PLG.CONTR. LIC. NO.
PLG
TOTAL
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
Y E] N E]
Y E] N EJ
MECHANICAL PERMIT FEE,'
hundred dollars ($100) or less.)
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so as to
BUILDING
become subject to the Workers' Compensation Laws of California.
Date Applicant
ALTER OR ADD TO MECH. 4.00
NOTICE TO APPLICANT: if, after making this Certificate of Ex-
APPLIANCE 4.00
PLAN CHECK
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10=C.F.M.) 3.00
AIR HANDLING UNIT (OVER 10=C.F M.) 5.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 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.
3097, Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
Lender's Name
Lender's Address
I certify that I have read this application and state that the above
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 3.00
PLUMBING
BOILER - COMP (3 H.P. or 100,000 B.T.U.) 4.00
BOI LER-COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC.- REFER TO ORD.,
(We.) agree. to save, indemnify and keep harmless the City of
C st liabilities, judgments, costs and expenses which
may in any wa accr d City in consequence of the
CONST. TAX
PERMIT ISSUANCE 3.001
sp r
granting of 'L
0of
fMECH CONT. LIC. NO.
MECH.
TOTAL
I
TOTAL
I
4/41
ApDate
OFFICE COPY