5118 APPLICANT TO-FILL IN INFORMATION WITHIN RED LINES - USE BALL POI N ONLY
BUILDING PROJECT I DENTIFICATI ON .PERMIT NUMBER
BUILDING' - ` , APPLICATION &'.PERMIT
ADDRESS / -
I - ^ ' � �riT� �TL f/Ei✓ , - BUILDING.ELECTRICAL-PLUMBING-MECHANIC 511
8
•OWNER'S "A PLAN CHECK VALIDATION
NAME DTV. ELECTRIC PERMIT FEE
MONEU /' ' .
• V P
CONTRACTORS
NAMOUTLETS-.SWITCHES-RECEP 5.00/1.00
/FF��/ ,npf
'1.C.K QU LIC.No. / �Q LIGHTINGFIXTURES - 5.00/1.00
ADDRESS pa APPLIANCES-RESIDENTIAL 4.00
CONTRA
_:rl P41 �, PHorvE' PANELS' 5.00 DATE OF APPLICATION
ARCHITECT W v d' (I'� SIGNS 6.00 PLAN CHECK FEE , P.C.NO.
OR
'
LIC.No SIGNS TRANS.. 3.00'ARCH.OR ,
ADDRESS ENG - -r ` SPECIAL CIRCUIT' '5.0D PERMIT VALIDATION
ZIP. - EMP.METER OR'POLE INS. 15.00 Q
APPLICANT'S MOTORS - SEE FEE SCH. PA J
• SERVICE CHANGE 10.00 . n
w o O' LICI:NSIiD CONTRACTORS DECI-ARAIION
.a v w I hereby ulfirin that Turn licensed under piavisions of Chapter 9 ISSUANCE ATE
N ( o niinen mg with Section 7000)of Division 3 of th Business anA
.¢w /. �a uu{{G n PLG. MECH.
H u a Pr ifLssions Co e,and my license is In lull force a II
zom p Ll asst ClLm Number- �fj YF IILLJJII
O'er r wl, Date (� Contractor -
¢ r ',' • - - - BUILDING PERMIT
Se -BUILDER DIiCLARATION'e^ - - -
A o.A u - INFORMATION
w 1 hereby uftirm that I am exempt from the Contractor's License' MISC.- REFER TO ORD
3 u y..: VALUATION $/FT.
FLLO¢- 'Law for the following reason(Sec.7031.5,liusinessand Professions r• PERMIT ISSUANCE 6.00'
Code:Any city or county whichrenuiresa permit loconstrua,alt6r, - aQ0
Se a,¢ o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0.' ELEC.' -
a
O LL squires the applicant far such permit to Ole a signed statement that _ i TOTAL - PERMIT TO
w S he Is licensed Imou nnl to the provisions of ibe Contractor's License
Zi Law(Chapter 9(commencing with Section 7000)ofDivision 3 of the - _4"
¢ Business andProfessionsCode)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE '
sio
¢ i- S the any
a fpr the alleged exam pilon.Any violation Otto a cion 7031:$ - STORIES TYPE CONSTR.
a3 _ by any applicant fora permit subjects the applicant trio Civil penuRy - ALTER-DRAIN'&.VENT-WATER'(EA.) 4:00
of not more than five hundred dollars f 5500L) -
❑ I,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 nut
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-'FLOOR,ROOF,AREA,COND. 4.00 - r
Code:The Contractor's License Law does not apply to an owner of
-� property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-' .
merits are not intended or offeredfor 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 (Ed:) 1.00 BUILDING USE
builder will have the bunch of proving that he did not build it int- " RES IND CON PB Omar
prove for purpose of sale.),' INDUSTRIAL WASTE INTER., ,20.00
❑ 1;as owner of the property,am Cx Closivdy contracting with ❑ El - ❑ El ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5'V.6
. 5.00 ASSESSORS PARCEL NO.
" unit Professions Code:The Contractor's License Law docs not apply ,
to an owner of property who builds or improves thereon,an(]who LAWN'SPRINKLERS-OVER 5(EA.) 1.00contra -
' the Co is Contract.,',
h proLicense
e L with a contraclod s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 .TRACT NO. PARCEL NO:
the Contractor i Liccnse Law.•.,
❑ I-amexemptunder See ,If.&BC.t'or this WATER HEATER W/VENT "` 4.00
reason
Owner Date, WATER SYSTEM 4.00 ACC.OATE ACC.FILE NO.
WORKERS-COMPBNSAffON DECLARATION WATER TREATING EQUIP, 4.00
I hereby affirm that I have a certiticale ofcomenl to self-in" ZONING
or'a certificate of Workers'Comminution Insurance,or a Certified ENG.SITE NO.
copy thereof(Sec.3800,LxhC.).
Policy Nk' Company .,'IS•� .
'0 ❑ Certified copy is here by furnislo KWA/ 2lf.s 44r.,3- 03;7 - FIRE SPR INK ENERGY T 24
Z ZO ❑ Cortil' py s til•da with tIL�� yinslction dlviniun. _ MISC.- REFER TO ORD. Y N Y N
Applicant 8L L4 ❑ ❑ t ❑ ❑
K �
CERTIFICATE 017 FROM WORKERS. ^ PERMIT ISSUAN CE .r 6.00 ♦- FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE', . PLG.CONTR. ,i LIC.NO. - PLG. . ,
d O V Y N
(This section need,sol be completed if.the permit is for are TOTAL ❑ N❑ ❑ -I ❑
Z hmodred dollars(S 100)of less.) '
U O mit),certify than in the performance of the work for whichAbis per. CITY. 'MECHANICAL PERMIT FEE FEE SUMMARY
LL F is issued,I shall not employ'any person in any mannerso as to -
U become subject to the Workers'Compensation Laws of California: Q O-V
_ ED Date- Applicant' ' ' - - ' x ALTER OR ADD TO MECH. 4.00 BUILDING
} m NOT'IGI?TO'APPLICANT: If,allci makFo,this Cerlificatu of fx- y _
F ? - emption,you should become subject to the Workers'Compensation - APPLIANCE .%. 4.00 PLAN CHECK
provisions of [be Labor Code, you must'forthwith comply with FEE S�
U such provisions or this permit shall be deemed revoked. _• AIR HANDLING UNIT(TO 10=C.F.M) 3.00
CONSTRUCTION LENDING AGENCY' AIR HANDLING UNIT(OVER 1000C.RM.) 5.00 SEISMIC FEE .
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(Sea MICROFILM
3097,CiaC.). - HEATING UNIT(TO 100,000 B.T.U.) 4.00
._ . .Lender's Name
NHEATING UNIT(OVER 106,000 B.T.U.)7.50
Lender's Name . ELECTRIC ,
1 certify Him I leave read this application and stale(hat the above VENTILATION FAN (SINGLE),, 3.00
information is correct. I wee to comply with all city and county - PLUMBING
ordinances and state laws relating to bolding construction, and BOILER-CONIP(3 H.P.or 100,000 B.T.U.) 4.00
hereby:autlmrjzc,oprewntalives of this City to enter.upon Ilia
aluove-mentioned properly lot Inspection purposes. BOILER-COMP(Over 100,000 BTU)SEE FEESCH. " MECHANICAL
^
t,(We) agree to sive, indemnify and keep harmlesx the City of MISC.- s REFER TO ORD. '
Cuiocrtum against liabilities,judgments, costs and expenses which CONST.TAX
' may in any way accrue against Said City in consequence of the PERMIT ISSUANCE 3.00
grand of this Permit. MECH.CONT. --LIC.NO. MECN.
,✓ TOTAL
�q TOTAL /
• Signat of App1'ant/Comnctor Date * -
.. OFFICE•COPV,