9319 APPLICANT TO FILL' IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER I
Im LONG APPLICATION & PERMIT /'� ;
ADDRESSAl
IA Es C_�e J J
r BUILDING-ELECTRICAL-PLUMBING-MECHANICAL JVE
R'S PLAN CHECK VALIDATION
NAME PTY. ELECTRIC PERMIT FEE
f PHONE_
NAME " ° UTLETS-SWITCHES-RECEP 10.00/1.00
C sp LIGHTING FIXTURES 10.00/1.00
0.NO. j
°P PPLIANCES-RESIDENTIAL 4.00
ADDRESS c'�`
1 PHONE PANELS 10,00 DATE OF APPLICATION
"AR HIT CPLAN CHECK FEE P.C.N0.
OR PANELS (OVER 200 AMP) 20.00 J•
ENGINEER
LIC.NO. SIGNS TRANS. 3.00 t
ADDRESS ENc' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
E,P EMP. METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
woo LICENSED CON'(RACTORS DECLARATION TEMP.POLE 30.00
a u s, I hereby affirn than 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
y a N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELE T. PLG. MECH.
F m Professions Code,and my license is in full force and effects ❑
o 0 w z- x License Class Lic.NumberT�b)�O ❑ ❑
Frw Date�••_I_$-�.�-Contractor )
Q y E J
ERMIT
¢ p/�¢ OWNER-BUILDER DECLARATION BUIL I G TION
o N D MISC.- REFER TO ORD IN RMATION
w3 N 1 hereby affirm that I am exempt from the Contractor's License
u0a Law for lhC following reason. 7031.5,Businessand Pw(esziOns PERMIT ISSUANCE 10.00 VALUA ON $/FT.
� - Code:Any cayor county which requircsapermit to C."'IucLalteq _
¢ ¢ QUO improve, or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. ///�
E O IS requires the applicant for such permit to file a signed statement that TOTAL (/✓ P RMIT TO
E
m m he is licensed pursuant to the provisions of the Contractor's License
� Z >
Law(Ch a,,c,9(,.in men,in,wit It Sec l inn 7000)o IF D iv kin 13 of t he
a Business and Professions Code)or that he is exempt therefrom and PTY. PLUMBING PERMIT FEE
r o the basis for the alleged exemption.Any violation of Section]031.5 SiaRIES PE CONSTR.
U.
n ; °s by any applicant fora permit subjects the applicant macivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(S500L):
❑ 1,as owner of Eric property,.r my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 Dec.GROUP RES.UNITS
their sole compensation,will do the work,and the structure Is not
intended or offered lin sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contract.,',License Law does not apply to an owner of
property who builds or improves thereon.and who does such work FIXTURES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTAL ACREAGE
himselfornot hrough
ownemployees,for sale.
If.ed ever,hat the
improve GAS-EA -SYSTEM6.00
mems arc not intended or offered for sale.If,however,the building
or improvement is sold within one year of lie did not,the owner- GAS-EA.SYSTEM-OVER 4-(EA.) 2.00 BUILDING USE
build.will have the barter of proving that he did not build or ins- 1
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 R ND CON PB Omer`,-,.
❑ I,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. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors 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 SEWER-SANITARY-STORM EA.200ft110.00
the Contractors License Law. RACT NO. PARCEL NO.
ElI at,,exempt under Sec. ,HAP.C.for this WATER HEATER W/VENT 6.00 .
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE N0.
WORK ERS'COMPENSATION DF,CLARATION WATER TREATING EQUIP. 5.00
I hereby affirm Ihat I have a ccritical,of consent to Self-insure. ZONING
` ^ or a certificate of Workers'Compensation Insurance or a certified ENG.SITE NO.
copy thereof(Sec 3800,Lab.C.).
Policy No. Company
Q . ❑ Cy!Kd Copy is hereby'furnished. FIRE SPRINK ENERGY T 24
Z'Z t�rtified copy is ftcd with IIIc city inspection division. MISC. REFER TO ORD.
O Ap ificant Y E] NE] Y [:] NE]irT PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
� CERTIFICATE OF EXEMPTION FROM WORKERS'
W > COMPENSATION INSURANCEPLG.CONTR. ,LIC.NO. PLG, V❑ N❑ Y❑ N❑
CL O (This section need not be Com pletcd if the permit is for one TOTAL
::) Z hundred dollars IS 100)or less.(
U O 1 certify that in the performance of the work for which this per- PTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- 'mit is issued,1 shall not employ any person in any manner so as W
Owbecome subject to the Workers'Compensation Laws of California. BUILDING
}
o. Dale Applicant ALTER OR ADD TO MECH. 5.00
W NOTICE TO API'LIC,\N'1': If,'stns,making this Certificate of Ex-
~ Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such Provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.N.) 4.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the prrtormance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00-
Lender's Name HEATINGUNIT(OVER 100,000 B.LU.)9.50
]-raiders,Address ELECTRIC
I certify that l have read this application and Stat,that thrabovr VENTILATION FAN (SINGLE) 4.00
. information 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.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(over 100,000 BTU1 SEE FEE SCH. MECHANICAL
ubovcanentioned property for inspection purposes.
(Wo) agree to save demnify unJ keep harmless the City of MISC.- REFER TO ORD.
Cuprrtil gar I Ilium ,judgments, costs and expenses which CONST.TAX
may ll any y accrue gainst said City in consequence of the PERMIT ISSUANCE 10.00
gra fng of i permit. LE'LxtC1rll �r MECH CONT. LIC.NO. MECH.
�� 72 .1 5 TOTAL TOTAL
- �' goal a Ya'cTr
)at
INSPECTOR COPY