C8523 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENT]FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT -7 8523
ADDRESS
",7( dAqrzoeasBUILDING-ELECTRICAL-PLUMBING-MECHANICAL
u
OWNERS PLAN CHECK VALIDATION
NAME
--� QTY. ELECTRIC PERMIT FEE
40 i
M12
CONTRACTORS ACTORS UTLETS SWITCHES ECEP 10.00/1.00
7 09•11& /LNT' G LIC.No. g LIGHTING FI S 10.00/1.00
CONTRACTOR'S - APPLIANCES 4.00
�, ADOR Ess q
3 S PRONE PANELS 0.00 .'DATE OF APPLICATION
OR
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
O
ENGINEER '�
uc.No. SIGNS TRANS. 3.00
ADDRESS ENGSPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP rrEMq.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCM.
f
ADDRESS J
p • 5A ti //7 SERVICE CHANGE 20.00 i
t;
w
oO LICCNSIiD TEMP.POLE 30.00 0 CONTRACTORS DECLARATION �J
` ¢ v U I Imreby affirm that 1 at,, licensed under provisions of Chaplet 9 l� ISSUANCE DATE
' y a N (commencing with Section 7000)of Division 3 of the Business and , N, `BLDG. ELECT. PLO. MECH.
Professions Code, ( P license is in full fore� &17
--r"
v bare,54"�t�,l� y z, i i ❑
.Z O.z License Clas'_({���k Lic.Number Jy7 y/ �\ ❑
LD Z Dale__:5 [/ Contractor
a x F BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILDER DECLARA PION
A o is. (a INFORMATION
I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
¢ oj Law for the following rcuson.(See 7031.5,Business and Professions PERMIT ISSUANCE 1u:00 VALUATION 5/FT.
� - o Code:Anycry orcounty which requiresa permit to construct.alter, (,.
a,¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. q/ lO ► /3.
e wo¢ requires the applicant lot such permit to the a signed sLOcnrcnl that TOTAL 6 (N PERMIT TO
m¢ he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
f E
Business and Professions Code)or Ihvl ha is csciapt therefrom and QTY. PLUMBING PERMIT FEE ID RTS
¢ H o O the basis for the alleged exemption.Any violation of8ection 7031.5 STORIES TYPE CONSTR.
u ; m by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00 / -df"e
Final more than Five hundred dollars(5500).1: C
Ar
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work.and the structure is not
intended or uttered for sale (Sec. 7044, Business and professions DRAINS-FLOOR,ROOF,AREA,COND, 5.00
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 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himscll or through his own employees,provided that such ire prove-
1 mems are not intended or offered for sale.If.however.the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM.OVER 4(EA.) 2.00 BUILDING USE:� builder will have the burden of proving first he did not build or im-
proveforpurposeofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PR o1m-1e�
❑ I,as owner of the property,am exclusively contracting with El El 1:1Ley - -
licensed contractors to construct fire project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
.ad 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 I'or such proutels with a contmetot(s)licensed pursuant to SEW ER-SANITARY-STORM E.A.2001t/10.00
the Contractor i License Law. TRACT NO. .t PARCEL NO.
❑ Iwo exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
' reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACG FILE N0.
.. WORK ERS'COMPENSA[ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconsC.t W self-insure. ZONING
or v cenifcate of Worker Compc....lion Insurancc,or a ccrlifil ENG.SITE NO.
'copy thereof(Sec.3800,Lab.C.I
Policy No. Company
O ❑ Certified copy is hereby fiunishe `Y / bC� 7 FIRE SPRINK ENERGY T-24
Z Z [,Certified copy is filed with I as ce ton division.
Z OL Applicant? .`G 2 ��--���� i_ MISC.- REFER TO ORD. Y❑ N Y ❑ N
� T CERTIFICATBOP EXP-MP[��RO!WORKERS• PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.UC.
LU > COMPENSATION INSU BANCfi PL .CONTR. LIC.N0. PLG.
d o H fit, section need not be complcled it the Permit is for one TOTAL Y❑ N Y❑ N❑
Z) Z hundred dollar,IS 100)or less.)
U O 1 certify that in the performance of fie work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any mvnner so as to
U become subject to the Workers Compensation Laws of California.
LU Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING Sv
} US NOl'WE 10 APPLICANT: If,after making this Certificate of Ex-
f- ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE 7
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 J
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 A
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
ordinances n correct.1 agree to comply with all oily and county PLUMBING
ordinances and slate taws relating to building lconstruction,citynco and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hen,by eulhorme C,V,ennti1. of this city In enter upon lite
above-memioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
4. HA
save, indeinnil'y aad keep harmless the City of MISC.- REFER TO ORD.
t liabilities,judgments, costs and expenses which CONST.TAX
IF accrue a st said City in consequence of the PERMIT ISSUANCE 10.00
ernri. MECH.CONT. LIC.NO. MECH.
`e S / rorAL TOTAL �/3 �7
icarUC ntrac or Date
INSPECTOR COPY
I