6966 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALLPOINT PEN ONLY
BUILDING PROJECT I DENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS (��"
a�s�3 /t1Rgl7,l} er BUILDING —ELECTRICAL—PLUMBING—MECHANICAL 6
OWNER'S PLAN CHECK VALIDATION
NAMETY. ELECTRIC PERMIT FEE
DNE�sa
CONTRACTOR UTLETS-SW'TC
HES-RECEP 5.00/1.00
NAME '/
tN /7C/aT/dJ(,n L,G.Na. 3Q yy92 LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'$
ADDRESS 77Q [',iir6J UT 5 r' APPLIANCES-RESIDENTIAL 4.00 _
— PHONE PANELS /S.00 DATE OF APPLICATION
pRCHnECT . SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
oDRESS END
SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00 q� ^
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
,1 SERVICE CHANGE 10.00
H oo LICENSED CONTRACTORS DECLARATION
¢ v I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
H < m (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r z Professions Code, nd my license is in lull force' td effect ❑ ❑
o license Class 7 Lin.Numbs ''i
9 so H wClinlractof'^ -+1=-- - ' T y'. .. —
a Y f w BUILDING PERMIT
¢ ¢ wa OWNER-BUILDER DECLARATION INFORMATION
wo u I hereby affirm that 1 um exempt from the Contractor's License MISC.— REFER TO ORD
3 u m VALUATION $/FT.
F LL o Q Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requiresa permit to construct.alter,
Rrt ¢ 2O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
w
On rcgmires the applicant for such permit to file a signed statement that TOTAL PERMIT T
i w m u, he is licensed pursuant to the provisions of the Contractor's License
rz >
Law(Chapter 9(commeneingwilh Section 7000)of DivSion3 ofthe (a C.
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
'.
¢ F o the basis for the alleged exemption.Any violation of Section 7031.5 ,STORIES TYPE CONSTR.
air' by any appli than
fora permit subjects $500).licunuoacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 4-00
of not marc Ilton live hundred dollars(8500).1: '
❑ I.as owner of the property,or my'employees with wages as BACK FLOW PROTECT. DEVICE 2.00 DCC.GROUP RES.UNITS
their Note compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,•ROOF,AR EA,COND. 4.00
Code:The Contractor's License Law docs not apply to an owner of
properly who builds or mproves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOORAREA TOTALACREAGE
• himself or through his own employees,provided that such intjirave-
ments are not intended or offered far sale.If,howeverthe 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 (EA.) 1.00 BUILDING uSE
bus[dor will have the burden of proving that he did not build or im- RFS IND CON PB Omer
t prove for pugvsc ol'sulu.), INDUSTRIALWASTE INTER. 20.00
❑ I,as owner of[tic property,ant exclusively contracting with E] ❑ E] E] ❑1
licensed cane ora-, m construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
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-OVER 5(EA.) 1.00
untracts for such projects with a mntraator(s)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
❑ 1 am exempt under See. BAP.C.for this r
n WATER HEATER W/VENT y, 4.00
nmsa
Owner Date WATER SYSTEM X4.00 ACC.DATE ACC.FILE NO.
WORKERS:COMPENSATION DECLARATION WATER TREATING EQUIP. ,.'4.00 s
I hereby elfin.. that Phave a cenillcaie`,af consent to self-insure.
ora certificate of Workers'Compensation Insurance,or it certified 1 ZONING ENG.SITE NO.
espy thereat(Sec.4800 lath C.) ,--,—I
]'.)he,No._16.11 /2Q nipany—G - �I
_.Q ❑�� �ctlil. hemlbylurni-I ti,-" # tr- _ -..gal:y:� -�y,;_�._p -.+ — 'L. - yS.FIRE SPRINK .ENERGY T*24 ;
Z Z 1 W Certific copy s N wltl 0 I uty s cion divixion - F -
- O Applicant MISC.- REFER TO ORD. y❑ N❑ Y ❑ N❑r
CE: y CER'I'117 CATE 01 1:X E M P I I ON F ROM WO R K ERS' PERMIT ISSUANCE +,6.00 FLOOD ZONE A.L.0 C.
LU > C(1.4Exl.AWION INSURANCE PLG.CONTR. LIC.NO. PL% YE] N❑ YE] No
11 U ('Phis section need not be completed if the permit is for one TOTAL
Z hundred dollars IS 100)or less.) -
U U 1 certify that in lire performance of the work for which this per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- "sit is issued,I shall not employ any person in any manner ,,as to
U become subjeel to the Workers'Compensation Laws of California.
U a Dam Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} w NO1'ICE'1'0 APPLICANT': If,after making this Certificate of Ex-
f— Z emption,you should become subject to the Workers'Com pensalion APPLIANCE 4.00 PLAN CHECK
Provisions of the Labor Code, you roust forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT ITO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 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(Sec. MICROFILM
3097,Ci,C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATINGUNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender',
certify iliatss Address
I have read this application andstate that the above VENTILATION FAN (SINGLE) 3.00
infornmtion 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
se /G,SQ
above-mentioned property for inspection purposes.
- .r
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Luper' o against liabilities,judgn ees, Costs nod expenses which PERMIT ISSUANCE 3.00 O CONST.TAX
ur . way accrue undnst Said City in consequence of the
gra ting of)Lisp It. MECH.CONT. LIG NO. MECH. T
/� / /f TOTAL/ Q TOTAL (/
Signamm of Applicant/COntmc o Date ,09-t—'I 'I��Tyn� ��44Q 0 O
INSPECTOR COPY '