6171 Permit `hPPLICANT TO FILL-IN INFO TION WITHIN RED LINES - USE BJ6 POINT PEN ONLY
• PERMIT NUMBER
BU I LDI NG PROJECT IDENTI FICA APPLICATION & PER
amLmNG
uzoo �. 6171
AD mess
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
NIR PLAN CHECK VALIDATION
NAME ,�// OTY. ELECTRIC PERMIT FEE _6
-JF6u
To -✓
do. PHONE -67
NOMEHAcroHs UTLETS-SWITCHES-RECEP 5.00/1.00
� 5 3 �
LIC.No, LIGHTING FIXTURES 5.00/1.00
Dora
ADDRESSDRESS - PPLIANCES-RESIDENTIAL 4.00
A
Pocnec PANELS - 5.00 DATE OF APPLICATION
RCHiTELr C3LZ/I/I SIGNS 6.00 PLAN CHECK FEE PC,NO.
E GINEER VTT
`A Q_ G SIGNS TRANS. 3.00
ARCH,OR END. �1• SPECIAL CIRCUIT S.QQ PERMIT VALIDATION
ADDRESS ..��ww��,,
1Oo G ST "'lZ2w // EMP.METER OR POLE INS. 15.00
APPLICANT'S MOTORS SEE'FEE SCH.
ADDRESS
U OU Vl1LL-F- --n SERVICE CHANGE 10.00
cy p L
o o LICENSED CON'T'RACTORS DECLARATION �% ° S
s• 2 u I hen•.by affirm thal I ant licensed under provisions of Chapter 9 ISSUANCE DATE
(crmnncocing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
yz Professions Code,and my I cnsc is in full Imee and effect. ❑ ❑ ❑
z o w I-icense Clans Lic.Number
o z r w Datc Contractor
a y E BUILDING PERMIT
¢ ¢ OWNER-BUILDER DECLARATION
IS
w
MISC.-• REFER TO ORD INFORMATION )
wo n r I hereby uftinn that I am exempt from the Contractor's License
FLLoa Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00 �v}}at,UnnON 5/FT.
Code Any city orcoiintywhichrequiresapermittoconstruct.alter, arp`0-0i000
rt ¢ O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
E
$" he is licensed pursuant to the provisions of the Contractors License a l
F z i
Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe r OF-iCe P
¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
sso(
¢ Fthe basis for the exemption.Any vioutton OfSeclion 7031.$ STORIES TYPE CONSTR.
m
u _ byanyapplicant fora permit subjects the applicant l0 a civil penalty ot mALTER-DRAIN -WATER (EA.) 4.00 Wofnore than five hundred dollars($500,b
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2,00 oet.GROUP RES.UNITS
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,COND. 4.00
Code The Contractor's License Law does not apply to ao owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve
meats ere not intended or offered for sale.It,however the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GASEA.SYSTEM OVER 4 (EA.) - 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
prove for purpose of sale.6 - INDUSTRIAL WASTE INTER. 20.00 ❑
❑ I,as owner of the property,am exclusively contracting with
- licensed contract.,, to canstmct the project(Sec 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:'I'he Contractors License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPR IN KLERS-OV ER 5(EA.) 1.00
contracts for such projects with a contractons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00
y reason
Owner' Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ISRS'COMPF SATI N DECLARATION WATER TREATING EQUIP, 4.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compauation Insurance.or a certified
copy thereof(See 3800,1' .1.
y ��C
Q Ccrliticd,npy'' robyf '.mod. FIRE SPRINK ENERGY T 24
Z 2 'ertifir y is 0 'th the c inspeainn Aivisiun. MISC.- REFER TO ORD.
O / Ari...... '� _ YE] NE] YE] NE]
� N 'I'IPICnTIi OF h\IiAtP NSOfPROM WORKERS'
x,4.PERMIT ISSUANCE 6.00 FLOODZONE A.L.u.c.
LU 5; CO Si PENSATI MINRANCE PLG.CONTR. LIC.NO. PLG.
CL Z (This section need not be completed if the permit is lir,one TOTAL Y E] N� v E] NE]
hundred dollws(5100)or less.) /
U O 1 ecrtily that in the ocriorncoce of the work to,Which this per- QTY. MECHANICAL PERMIT FEE FEE SUPAMARY
LL F mit is issued.I shall not employ any puma h.any manner sn as to
Ow became subject to the Workers'Compensation Laws of California. pe
Q. Owe nPplicanl '- ALTER OR'ADD TO MECN. 4.00 BUILDING
} tD NOTICE "10 APPLICANT': If.after making this Certificate of Ex-
Z emotion,you should become subjeet'Ia the Workeri Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code;you must forthwith comply with FEE
U such...... Wins o,this Permit shall be deemed revoked. AIR HANDLING UNIT(TO JOQWr_F.M.) 3.00
u4
' CONSTRUC'T'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000 C.EM.) 5.00 SEISMIC FEE
I hereby a(tirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the pertornmuce of the work for which this permit is issued(Sec. MICROFILM
3097.Civ.C.), HEATING UNIT 170100,000 B.T.U.) 4.00
Lender's Name
Nauru H EATING UNIT(OV ER 100,000 B.T.U.)7,50
Lender's s ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
infornatian is coronet. 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 autlm9rnze representatives of this city to enter upon the BOILER-COMP Mia,,100,000 BTU)SEE FEE SCH. MECHANICAL
above-murMmed proper) inspection purposes.
ON agree to ; indemnify and keep harmless the City of MISC.- REFER TO ORD.
C rtlno again lines.judgme its, costs and expenses which CONST.TAX
a wa a { ad Cit`ikcor*gj.pyx, otibe PERMIT ISSUANCE 3.00
s :CONT. LIC.NO. MECN.
Sig stere o p li a oniractor U e TOTAL / TOTAL
I INSPECTOR COPY'
t