6959 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 6959
ADDRESS
5e. BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNLH'S PLAN CHECK VALIDATION
"AME QTY. ELECTRIC PERMIT FEE
• I ,AVN �/L
c Nr a airs g7�-y6� UTLETS-SWITCHES-RECEP 5.00/1.00
N M
SW U LIGHTING FIXTURES 5.00/1.00
r. Nmactoe'S
an1-'130.._/!/l0 PPLIANCES-RESIDENTIAL 4.00
on Ess �^\ / C/�
3 j5 �ffA/ lpViavyL PANELS 5-00 DATE OF APPLICATION
ARLRITECTSIGN$ 6 OO PLAN CHECK FEE P.C.NO.
on
ENGINEEN
' L.C.NO. ' SIGNS TRANS. 3.00
ADDRESS ENGSPECIALtCIRCUIT 5.00 PERMIT VALIDATION
zip TEMP.METER OR POLE INS. 15.00 r
Ars MOTORS SEE FEE SCR. cll�J
ADDRESS
- SERVICE CHANGE 10.00 /// �•
u0F'o a LICENSED CONTRACTORS DECLARATION .�
G o La I herchy Alum that I am licensed under Pmvisime:of Clmple,9 ISSUANCE DATE
I 2 w (commencing with Section 7000)of Division 3(it the Business and BLDG. ELECT. PLG. MECH.
.w z d'ml'essions Cyt y�s�yyll ��tt I all force and effect. ❑ ❑ 1:1 ❑
O,n / Licmruu Clan, ._LSI IR 1%."her
w Uulc_ a �y Contractor
c y 2 , I� Y BUILDING PERMIT
Ie a u OWNER-BUILDER DECLARATION INFORMATION
R
3 r 1 hereby`alfirm that I um exempt from the Conlractor's License MISC.- REFER TO ORD
LL o¢ Law for the following reason.(Sec.7031.5.Busuessund 1'rol'essions PERMIT ISSUANCE VALUATION $/FT.
6.00
Code:Any city Dr county which requires a permit to constn¢L alter,
rt¢ p impnwe,demolish,Oe repair any structure,prior le its issuance,also ELEC.CONTH. LIC.NO. ELEC.
O B,requires the applicant for such permit to file a signed statement that TOTAL 'PERMIT TO -'
d w se he is licensed pmsuanl to the provisions of the Contractors License
F z a
Law(Chapter 9(commencing with Section 7000)of Division 3o Fiji,
Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
r Oo the basis for the alleged exemption.Any violation of5ection 7031.5 STORIES TYPE CONSTR.
ou a3 _ by any applicant for a permit sub,,,t,the applicant to a civil penally ALTER-DRAIN& VENT-WATER (EA.) 4.00
of not mom than five hundred dollars(S500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sMe compensation,will do the work,and the x ruclure 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 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.
lents are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
impruvnneni is sold within one year of completion,the'owner-
milder GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
„ hrove f will (lave the burden of proving Ihm hs AiJ not('build ur an. RES IND CON Pa Orher
Prow for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ L a owner of the properly,he rojectiv Se contracting with ❑ ❑ ❑ ❑ ❑
licensed miens ors to construct the project La 7044,of apply LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO,
and frowner of Codex The Contractor's License Law does not apply
to an cts for
OF property who builds or improves thereon,and who LAWN SPR IN KLERS-OVER 5(EA.) 1.00
the
for rush projects with a contractor sl licensed pursuant m
the Contrucwr's License Law, SEWER-SANITARY-STORM EA.2001t/8.00 TRACT NO. PARCEL NO.
❑ lam caempl under See ,B.RP.C.for this WATER HEATER W/VENT 4,00
malles
Owner Dale ''WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION UECLARA'IION WATER.TREATING EQUIP. 4.00
I hereby afro.. that I have a reirme to of consent to self-insure 20NIrvG
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE N0.
cops'Ihereof(See.3800,Lah,C.).
Policy No. Company 1
t.1 Cmlili 6CONiPFNSA1
by IIRmhcd. FIRE SPRINK ENERGYT 24
o/yC,r1iNnetl a city inaxni n Jivisinn. MISC.- REFER TO ORD.
APPliwn Y❑ N❑ Y ❑ N❑PERMIT ISSUANCE 6.00FLooO zoNE A.L.u.c.
°IXEMPTION PROM WORKERS'LD 'ION INSURANCE PLG.CONTR. LIC.NO. PLG.
D
Z 1'I'[,I, .,titin need not be completed if the permit is for one TOTAL Y[:] NE] Y E] N❑.
hundred dollars 15100)or less) I -
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
Il I- mit is issued,I shall nut Cm ploy any per..n in any manner sn as to
00 become zLbjedl to the Workers'COmpcnsalioR Laws of California. BUILDING
n. Dat° Applicant ALTER OR ADD TO MECH. 4.00
} to NO'TICI: 1'O APPLICANT: If,after making this Certificate of Ex- -
F2 emptiml.you should become subject to the Worken'Compcmalion APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such D...swona or this permit shall be deemed revoked. - AIR HANDLING UNIT(TO 10MC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that (here is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the p doom ,c of the work for which this permit is issued(Sec MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
L,ndcr's Address HEATINGUNIT(O VER100,000B.T.U.)7.50 ELECTRIC
1 certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
• information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-OOMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorise representatives ol' this city to enter upon tlm BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL a/
above-mentioned property for inspection purposes.
(We) agree to tare, indemnify and keep harmless the City of MISC.- REFER TO ORD.
o ag st liabilities,just ts, costs and expenses which CONST.TAX
nay in ny y acee�t�� tyacne, of the PERMIT ISSUANCE 3.00granting f l peemiLMECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
e of Applicant/ e
INSPECTOR COPY