C8360 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
0ILDBUILDING PROJECT I DENTIFICATI ON APPLICATION & PERMIT PERMIT NUMBER
aING n J
ADDRESS BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
1012-0 n
v 8 3 6 o
OWNER'S / PLAN CHECK VALIDATION
al NAME QTY. ELECTRIC PERMIT FEE
Y ( PHONE 414-
NAMEnacTDRS OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No. r LIGHTING FIXTURES 10.00/1.00
r, TR R's PPLIANCES-RESIDENTIAL 4.00
ADDRESS
CH CTHONE _ PANELS 10.00 DATE OF APPLICATION
l P. .
on PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE CNO.
ENGINEER
uc.NO, SIGNS TRANS. 3.00
ADDRESS eea. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 ^ p
APPLICANT S
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
0 o O LICENSED CONT RACTORS DECLARATION TEMP.POLE 30:00
F i WI hereby affirm that 1 am licensed under provisions of Chapter') ISSUANCE DATE
(conunencing with Section 7000)of Division 3 of the Business and
y a 1, BLDG. ELECT. PLG. MECH.
w z Professions Code,and my license is in full force and effect. ❑ ❑ ❑
a, o m - License Class ( Lic.Number r
O o uiO r Date �B Lie.Contractormb p-➢ �" ' s
¢ ¢ a
OWNER-BUILDER UECLARA'I']ON BUILDING PERMIT
A o a u INFORMATION
I hereby affirm that I am exempt from the Contractor's an ors License MISC.- REFER TO ORD
u_oa Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
ce Code:Any city or county which requiresapermit to construct,alter, )) t
rt ¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE, LIC.NO. ELEC. pC S 7v
n w m u requires the applicant for such permit to til,a signed statement HIM TOTAL , PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
H Z s- Law(Chapter 9(commencingw'ith Section 700()ofDmsion 3 of the �A/TEQr,.OR r O
4 D Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE H
zwz
¢ I-a the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than live hundred dollars(S500).):
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044. Business and Professions - DRAINS-FLOOR,ROOF,AREA,COND. 5.00
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 5.00
SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such im P¢nc.
mots are not intended or offered for sale.If,huweveq the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
0 1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sce. 7044,BusinessLAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORSPARCE-NO.
and Professions Code:The Contractor s`License Law docs not apply
1" 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 conlractous)licensed pursuant to
the Contractors License Law. SEWER-SAN ITARV-STORM EA.2001t/10.00 TRACT NO. PARCEL NO.
O I am exempt under Sec,-,B.&P.C.for this WATER HEATER W/VENT 6.00 «w
reason
Owner ])life WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. .
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
hereby affirm that I have a certificate ofemisenl to self-insure,
/ or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
--L copy thereof(Sec.3800.Lab C... _
PolicyNO. company
i E
, Y ' a1�. 1 316
O O Certified copy ixs BIN form lie FIRE SPRINK ENERGY T14
z Z LT •NifiedopY is filed ithhe inspection divisidfi^ - 'v
i).-7 A jca, III--) ` MISC.- REFER TO ORD. Y [] N� v ❑ NE]
I-- rn �-Ilk vy- `r PERMIT ISSUANCE 10.00
� - CERTIFICATE OP IiXIiMPPIOY I'RG,V WORKERS' FLOOD ZONE A.-.u.C.
LU > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG,
d In !'Phis section reed not be completed if the permit is for one TOTAL v N v N
::) 2 hundred dollars IS 100)or less)'
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL i mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
0a,4 Dale -Applicant ALTER OR ADD TO MECH. 5.00 BUILDING ��Sa
_ } to NOTICE TO APPLICANT': If,after making this Certificate of Ex-
♦- Z lanio on,you should becmm,subject to the Workc,,Comp,n,iU R 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 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 1000C.EM.) 6.00 SEISMIC FEE S-tj
I hereby affirm that there is a moomction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance mf the work for which this p,Rm it is issued(Sec. MICROFILM
3097,Ci,.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U. 9.50
Lender's Address ELECTRIC _
I cvrtity that-I have read this application andstat,tilt the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county PLUMBING
1 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 ODOR the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(W to save, indemnify affil keep/harmless the City of MISC.- REFER TO ORD. s
Cu lino agai st liabilities,jus •eUs, co;qJs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any ay acc, a •uinsl s d City/in consequence of-the
g{dnli ng of 1 s peon j1. I / / MECH.CONT. LIC.NO. MECH.
U °TA` TOTAL
Signitifturi yipirailriContractorl Date
I
INSPECTOR COPY
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