6271 / APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING Lo ? .-0 APPLICATION & PERMITADD
L tie BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 6271
bG i
WN4 '+ PLAN CHECK VALIDATION
E - CITY. ELECTRIC PERMIT FEE
.opONE
CONTRACTORs
NAME OUTLETS-SWITCHES-RECEP 5.00/1.00
•
cic.No.WLIGHTING FIXTURES 5.00/1.00
AE s
foNTRa T Irs PPLIANCES-RESIDENTIAL 4.00
ODH
F oNE - PANELS - ' 5.00 DATE OF APPLICATION
A@CI rt CT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
N Cu`
ENGINEER
LIc.NO. SIGNS TRANS. "3.00
.ARCHHi RENG,SS SPECIAL CIRCUIT �, 5.00 PERMIT VALIDATION
-' ala EMP.METER OR POLE INS. FE 15.00 Q�/
APPLICANTS MOTORS SEE FEESCH.noOHEss
SERVICE CHANGE 10.00ooLICENSEDCONTRACIORS DECLARATION ��J
a U s~a 1 hereby alfunl that I am licensed under provisions of Chapter'/ ISSUANCE GATE
cl N a A (commencing with Section 7000)of Division 3 of the Businessamd BLDG. ELECT. PLG. MECH.
F m i I'rolls5ions Code, my license is in full force' cif•
z 0. - License C Lie.Numbe ❑ ❑ ❑
9 z L °w Uucc �_(_�- .d7?n_Cor for
a y s BUILDING PERMIT
¢ ¢ w a
OWNER-BUILDER DECK AT'ION INFORMATION
" MISC.- REFER TO ORD
`w 3 A r 1 hereby attinm that 1 am exempt IF theContrac is License
e, o g Low for the follown.following reusu (Sac.703 I.S. ssand 5,BusinProfessions
PERMIT ISSUANCE 6.00
VALUATION S/FT.
rya
Code:Any city or coon ty which re4uires upennit to construct,alter, q l F
r' `- ELEC.CONFER. LIC.NO. OC Ko
¢-� a Z iminies demolish,or for such
any structure,poor to its issuance,also ELEC. /
¢ ¢¢I ulres the applicant for xtlClh peon((10 De a signed Statement Ilial TOTAL PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's License
r z r Law(Chapter 9(emorm, cingwith Section 70000.1'Division3 ofthe S'w F(,C' .4 /
St Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE '
ce tire basis for the alleged exemption.Any violation of Section 70313 STORIES TYPE CONSTR.
LL
; m by any applicant far a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(S500p.),
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE • 2.00 OCC.GROUP RES.UNCES
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,CONE). 4.00 R j
Code"flee Contractor's License haw docs not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 SD.FT.FLOOR AREA TOTALACREAGE
himself or Through his own employceS,provided that such improve-
., meds are not intended or offered fur sale l f however,the huildu'g GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00 �L(p
OT 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 Ilia(he did not build or int- RES IND CON PB Omer
f prove I .......se ofmle.). 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. 5.00 ASSESSORS PARCEL NO.
and Professions Code The Contrac(or's License Law does not apply
w to ao owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00 '7Z,2-�jGs 03,e'
contracts for such projects with a contracmrls)licensed punm int to
Ilse Contractor;License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ tum exempt under Sec. .B.&Poco for this WATER HEATER W/VENT 4.00 �0�40
sm
2 Ow'm' Date WATER SYSTEM 4.00' ACC.DATE ACC.FILE No.
wORKERS'COMPIi NSATION DECLARATION WATER TREATING EQUIP. 4-00
1 hereby affirm that I have a ccuilwatc of......cut to oil-insure, ZONING ENG.SITE NO,
or a certificate of Worker;Compensation Insurance,or a certified
...py thercof(Sec.3800,Lan C.).
Pah No. Company_
0 pl$�Y Cetli fled . y is hereby fungi l N FIRE SPRINK ENERGY T 24
Z 2 /❑`Cert if 'or'
o ry is f cd wit dit city ins a ion division. MISC.- REFER TO ORD.
O Applicant Y ❑ N❑ Y ❑ N❑
� N CIiRT117 '1'Ii OF I: EA1 FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE .L-U.C.
k- LU -OMPIiN Al'IONPI' SURANCE PLG.CONTE. LIC.NO. PLG.
EL 0 1'1'his vectid need not be completed if the Fermi( is for one TOTAL Y❑ N❑ Y❑ N❑
y 2 hundred dollars(S 100)or less.)
U O 1 certify (hut in the pc,fonnmwe of Ole work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
�_LL I- leu is issued,1 shall let enhploy any person in any manner so as to -
U Income subject e Workers'ConhI e nsation Laws of California.
e 110� y BUILDING
Uatr• Ie to tire Applicant - ALTER OR ADD TO MECH. 4.00 av
} to NO]ICE 10 APPLICANT': If.after making-(his Certificate of Ex-
F 2 enhpc on,you should become subject to the Worker;Compalsation APPLIANCE 4.00 PLAN CHECK
provisions of the Lsbor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10000C.F.M-) 3.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER IOAOOC,F.M.) 5.00 SEISMIC FEE
t I hereby afforn 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.0-). HEATING UNIT LTO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Name ss NHEATI NG UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I ce,ily chat l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
inf..riapon is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspect ion purposes.
(we) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cu er no against liabilities,judgments, costs and expenses which CONST,TAX
y if I any way accR in
ngxsl mCity io co
id Cinsequence of the PERMIT ISSUANCE 3.00
•mai {f of lhc,pr,mI MECH.CONT. LIC.NO. MECH.
31 OTAL TOTAL 0 17.11 Y
ureof Ap ;can ntNcor /
( INSPECTOR COPY