6960 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
Q •�/ -ZZBUILDING6960
OwNER'I (D PLAN CHECK VALIDATION --
NAME IT ELECTRIC PERMIT FEE
pNTRAc
NA TDRs UTLETS-SWITCHES-RECEP 5.00/1.00
IN5N La LIGHTING FIXTURES 5.00/1.00
C NTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADORES
S
PANELS 5.00 PATE OF APPLICATION
ARCHiTECT SIGNS - 6.QU PLAN CHECK FEE P. .NO.
OR
ENGINEER
LIC.No, ISIGNS TRANS. 3.00
ADDRESS END. 5.00 CIRCUIT B-QQ PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 15.00
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00 i
o O LICENSED CONTRACTORS DECLARATION
a u. I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
.N <w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H m I'mfes'sio�OWNIR:BUI
s in full force rola clTccd. ❑ ❑ ❑ ❑
License C �nber
Q m Dam t clota DECLARATION BUILDINGPERMIT
S ¢ w INFORMATION
o A REFER TO ORD
w S o'r hereby affirm Out I so exempt from the Contractor's License MISC.-
LLO¢ Law for thebillowing reason.(Sec. uires BusireSsand rocontract.ssions PERMIT ISSUANCE VALUATION $/FT.
Crede ve,Any def ty or countypair any structure,
requires permit toconsuanc alter, 6.00
La 4 g0 improve,dannlish,or repair any structure,prior to its issuance,also ELEC.DDNTR. LIC.NO. ELEC.
ic -0 ¢ ¢quires the applicant for such permit to fdc a signed statement thus TOTAL PERMIT TO
u w m n he is licensed pursuant to the provisions of the Contractor's License
Hzi
Law(Chapter 9(coin meRuing wit It Section 7000)ofDivision3Ofthe
a Business and Professions Code)or that he isexcorpt therefrom and OTY. PLUMBING PERMIT FEE
R IT- o the basis forthe alleged exemption.Any v iolatioo o fSectio.7031.5 STORIES TYPE CONSTR.
n „- by any applicant for.r permit s.Ijcct,the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(5500).):
'❑ 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 Dot
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.Provided that such improve-
...ends are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement Is sold within one year of completion,lire owner- GAS=EA.SYSTEM-OVER 4(EA.) 1-00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Other
Prove for propose of via). 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.
.ul 1'rofcasians Code:The Contractor's License Lnw docs 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 contmctorls)licensed pursuant 10
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
Cl Iwo exempt unAcr Sea ,B.&P.C.for this WATER HEATER W/VENT .4.00
reason
Owner Date WATER SYSTEM 4.00 ACC-DATE ACG FILE NO.
W'ORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby alTirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance.or a certified
/ copy thereof(Sec.3800,Lab.0-L
Policy No. Company
Q ❑ Ccr Icl co is herebyrlt nhyQ. / - FIRE SPRINK ENERGY T 2
Z Z ❑ C di(ic til In/Ulerci ,'1p' Af mviaion:
Applic. a _ J! y�/ MISC.- REFER TO ORD. V❑ N❑ Y ❑ N❑
CC CP '1'I PICA'1'1:Olr 1 XEMPI'ION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE AT.U.C.
LU > COldl'17NSATION INSURANCE PLG.CONTR. LIC.NO. PLG. YE] N[] V❑ NE]
('Phis section need not be completed if the permit is for one TOTAL
Z hundred dollars IS 1000or lcssJ r
U O I certify that in the.performance of Om work for which this per. DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued, I shall nol employ.m y'person in any mannose as I-
0 U becomsubject to the Workers'Compensation Laws of California.
U y Ualn Applicata ALTER OR,ADD TO MECH. 4.00 BUILDING
} 0 NOl'ICE 1'O APPLICANT': If,aHer making IN,Certificate of Ex-
� Z eruption,you should become subject to the Workers'Compensation APPLIANCE 4.00 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,OIJOC.F.M.) 3.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE
I hereby a firm (hat Omre is a construction lending agency lin EXHAUST HOOD(WITH DUCT) 2.00
the performance of Doe work for which this permit is issued(Sec. T W MICROFILM
3097.Cis,C.), HEATING UNIT(TO 100,000 B.T.U.) 4.00
LNamAdd,ender's HEATING UNIT(OVER 100,000 B.T.U.)7.50
`-
Itender's es ELECTRIC
1 certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct.1 agree to comply with all tidy and county rN PLUMBING
ordinances and stale lows relating In building construction, and
BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 Az
hereby milli nrve representatives of this city to enter upon the BOILER-COMP (Over 100,000BTU)SEEFEESCH. SZ MECHANICAL
ab uvo-mcntiuocd properly for inspecDon purposes. V
(We 'ree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cu Lino gni liabilities,judgments,costs and expenses which CONST.TAX
C
in a y accrue as et sai .ity in consequence of the PERMIT ISSUANCE 3.00 ✓Y
anlingr permit. MECH.CONT. LIC.NO. MECH.
/6 TOTAL 30 i TOTAL
/ 16 eof pplicant/ o actor Date
INSPECTOR COPY