C8462 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT /
�e ADDRESS •Z,^Z'�e� I{QV1AF$TF 1a'� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL , 1,
CA Q 51
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
• D°ME""OTOR UTLETS-SWITCHES-RECEP 10.00/7.00
LIC.NO. LIGHTING FIXTURES 10.00/1.00
TRAC
CONTOR'S
ADDRESS
CONTRACTORS
APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
• LIC.No. SIGNS TRANS. 3.00
• - ADDRESS ErvG' SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLICANT'$ MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
rt U w I hereby uff3rm that I am licaued under provisions o(Chapter 9 ISSUANCE DATE
y (commencing with Section 7000)of Division 3 of the Business and
¢ u 6 1J. ELECT. PLG. MECH.
H i Professions Code,and my license is in full force and effect. ❑ ❑ ❑
Z o H - License Class Lic.Number
o z D D'ulc Contractor
H - J
ams J ,� BUILDING PERMIT
EE I[ w a
hOWNER-BUILDER DECLARATION j
K0ca MISC.- REFER TO ORD INFORMATION
w ; w hereby affirm that I am exempt from the Contractor's License
.. Oj Law for the following reason(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
� -0 Code:Any city mcounty which requires a permit to construct,alter, `
¢ m¢ >¢ J L�c�
improve,Demolish,or repair any sdnetumprior to its issuance,also ELEC.CONTR. LIC.NO.
u m u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w he is licensed pursuant to the provisions ofthe Contractor's License /
Z i Law(Chapter 9(commencingwitll Section 7000)of Division 3 of the
a Business and Poofieeeions Code)or that he is exempt thercfiool and QTY. PLUMBING PERMIT FEE
¢ Ii*- $ the basis for the alleged exemption.Any violation of Section 7031.5 1 IsIGFREs TV ECO S R.
a by any applicant for a Permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(3500).):
O I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compelsation,will do the work,and the structure Is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,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 F IXTUR ES-PER TRAP - 5.00 SO,FT,FLOOR AREA TOTAL ACREAGE
himself or throtlglf his own employees.Provided that such improve-
- � mentsare not intended or offered for sale.if,however,the building GAS-EA.SYSTEM-11NC.4 OUTLETS 6.00
or improvement is said within one year of completion,the owner- GAS EASYSTEM OVER 4 IEA) 200
builder will have the burden of proving that he did not build ar if.- - . - . .
- BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ ,I;as owner of tiro property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- I INC 5 V.B. 6.00 ASSESSOR CRO.
cad Professions Code:The Contractor' License Law docs ,at apply
to an owner of property who builds nprove'thereon,and who LAWN-SPR-SPRINKLERS-OVER 5 (EA.) 1.00
con tincts for such Projects withacol ructortsl bcens,d pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contract under
W.
❑ 1 am xempl muter e. B.&1'.C.Gn this
reason _ 7 4(�-' WATER HEATER W/VENT 6.00 ,
Owner l ^ Date .{ WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORKERS'C6l1PFN5,\TICMcCCrlRAT10N WATF,R TREATING EQUIP. 5.00 \
I hereby affirm Ond 1 has,a certificate o(cousent to wi Hinsare, / ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company -
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY 24
Z Z ❑ Certified copy is filed with the city inspection division.
MISC.- REFER TO ORD.
O Applicant V❑ N❑ V❑ N❑
CC CERI'll%CAI'1:OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.UC.
L C'OhIPENSATION INSURANCE PLG.CONTR, LIC.NO. PLG.
CL Z (This section need not be completed if the permit is lift one TOTAL Y[:] NE] V ❑ N❑
hundred dollars IS 100)or Iess.)
U O 1 certily that in the performance it life work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
L I- Init is issued,I shall not employ any person in any none,so as to
U become subject to the Worksr,'Cmrpcnsation Laws of California.
Go Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING r j'7j
>_ 0 NOTICE TO APPLICANT: If.alter making this C,nificate of F,-
F" ? emptiou,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE eo�
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000CF.M.) 4.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.EM.) 6.00 SEISMIC FEE a�
1 hereby afliml Oml there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of lire work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.0-) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)8,50
Lender's Address ELECTRIC
I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and county BOILER-eOMP13 HP.or 100,000 B.T.U.1 6.00 PLUMBING
ordinances and state lows r sting to building Construction and
abovrmentionnl property purposes. .
berehy authorieu represents I es of this city to color upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
fo i spection
n'tnany
save, inde tu y and keep harmless the City of MISC.- REFER TO ORD. '-
liabilities,j d mends, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
' t said City in conseque of theEnt id. MECH.CONT. LIC.NO. MECH. G
c OTAL TOTAL
\ 5 gnu are n p I . ract Da
� INSPECTOR COPY