7148 APPLICANT.TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT'PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
D
ADRESSILDIN I - PLICATION & PERMIT n ��
4e -PLUMBING -MECHANICAL r
t.A. OWNER'S PLAN CHECK VALIDATION
NNAME ELECTRIC PERMIT FEE
• R PMON
CONTRACIHORS
NA � , ,y/ O L TS-SWITCHES-RECEP 5.00/1.00
LI LIGHTING FIXTURES 5.00/1.00
N " PPLIANCES-RESIDENTIAL 4.00
'= Ap RE s
*�. P 7- PA ELS 5.00 DATE OF APPLICATION
ARG.ITECf SI NS 6.00 PLAN CHECK FEE V.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
it ADDRESS
- ., SERVICE CHANGE 10.00 S�
F
00 LICENSED CON'I'RACfORS DECLARATION
"L,v., I hereby affirm that I am licensed under provisions of Chupto,9 ISSUANCE DATE
H 2.w (ppm...coin,with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r•w Z Professions Code,and my license t.in full force'
,e 0 m- License C s Lia Number 0 El
Q - 0 Dae Contruclar
nj
xi " � BUILDING PERMIT
at 2 ce a MER DECLARAT INFORMATION
- REFER TO ORD
w 3 u 1 hereby affirm that I am exempt from the Contractors MISC.
License VALUATION $/FT.
F .. o a Law for the following reason.(Sea 7031.5,Rosiness and Prolcssions PERMIT ISSUANCE 6.00
Code:Any city orcounty which requires a permit to construct,alter,
2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NQ ELEC.
- o u requires the applicant for such permit to file a signed statement that TOTAL PERMITTO
a w As he is licensed pursuant to the provisions of the Contractor's License
Law(Chap IS,9(commencing with Section 7000)of Division 3 of t he
<'•+f Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
ce I c the basis for the alleged exanption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
dam
by any applicant for a permit Subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars($500)):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
1,t their cele compensation,will do the work,and the structure is not
-4 intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
;N 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.FLOORAREA TOTALACREAGE
. himself or through his own employees,provided that such improve-
mentsarenotintendedorolTeredforsale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner-
, builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM.OVER 4(EA.) 1.00 BUILDING USE
prove for purpose of sales). RES IND CON PB Omer
_ O I,as owner(if property,am exclusively contracting with INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑ ❑
licenwd contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:1'he 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
contracts liter such projects will,a cmnlractous)licensed pursuant to
the Contractor's license law. SEWER-SANITARY-STORM EA.200ft/B.00 TRACT NO. PARCEL NO.
❑ Ian.exempt under Soc. .B.&fsC.for this WATER HEATER W/VENT 4.00
1.1 re'J\SII
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARA'rION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent o sclGinsure, ZONING ENG.SITE NO.
or
cel.mate of Worker'C. is .c' n In ranee, erlifieJ
a p l e /
1' f n py y
0� e Flfc}c y u FIRE SPRINK ENERGY T"24
z Z ❑ r fi - fled wit tl ci insP' 'oh suis n -
O. AW, MISC.- REFER TO ORD. v ❑ N❑ Y ❑ N❑
� y C'.RI'IFI CA'IE 0-EXL NFROM WORKERS' PERMIT ISSUANCE 6.00 kf
LOOD ZONE A1.DA.
' LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO, PLG.
0:Z 1 '1'In, section need not be completed if the permit is for one TOTAL / Y❑ NE] Y E] ❑
N
hundred doll...IS 100)or less.)
U O I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
Il'H alit u issued,I shut]not employ any person in any manner so as to
"O beco".e subject to the Workers'Con.pensation Lawsof California.
O:'w BUILDING
a Dam ICAN1:m ALTER OR ADD TO MECH. ' 4.00
}.rn con,oiNOI CIi ..I Auiold .4N'I': IL after making this r,'Coope of F:x-
F'Z provision you should became subject m the Workers Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the labor Code, you muss forthwith comply with FEE
such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M1 3.00
V
ryis t AIR HANDLING UNIT(OVER 109MC.F.M.) 5.00 SEISMIC FEE
y
r� I 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.C.e.CJ. HEATING UNIT(TO 100,000 B.T.U.) 4.00
- Lender's Name
Lender's AJdruss R HEATING UNIT(OVER 100,000B.T.U. 7.50
' ELECTRIC
- I certify that I have real This application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct.I agree to complyxwith all city and county PLUMBING
+, ordinances and state laws relating to building construction, and BOILER-COIvP(3 H.P.or 100,000 B.T.U.) 4.00
hereby autlarizc rcpresentativcs of this city to enter upon the BOILER-COMP Bove,too,00d'BTU)SEE FEE SCI, MECHANICAL
above-mentioned property her inspection purposes.
(we) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
. 7r Cupertionagainst liabilities,judgments,.costs and expense which CONST.TAX
y in any,way
to g.mst said City III Jsequence of the PERMIT ISSUANCE 3.00
r lin& f This permit. CONT, LIC.NO. MECH.
TOTAL TOTAL
Si to of p it azmr Date
INSPECTOR COPY
ea