9520 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT'1 DENTI FICATI ON PERMIT NUMBER
BUILDINGn n APPLICATION & PERMIT
AA91 LA-�W2 VT. BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 9520
J OWNER'S PLAN CHECK VALIDATION
" EV/) `g#4 / 4��, (•Z QTY. ELECTRIC PERMIT FEE
Ilk ` CTOR '•I/�/ PHONE �Cd
NON ERAcroRs _ /,7z OUTLETS-SWITCHES-RECEP 10.00/1.00
/,S (,(/)'V�,( �-S�7// LIGHTING FIXTURES 10.00/1.00
IC N0.
CONTRA a APPLIANCES-RESIDENTIAL 4.00
T IATDORES;/ /J/� 1 [//`�J)
p //^ PHONL�/ /•'C PANELS 10.06 DATE OF APPLICATION
OR
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCHHEOR ENG. SPECIALCIRCUIT $,QQ PERMIT VALIDATION
+
ZIP EMP.METER OR POLE INS. 20.00
APPLICANT$
ADDRESS MOTORS SEE FEE SCH. 0
(\ � i
SERVICE CHANGE 20.00
oo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 /
a v o I hereby affirm (hat I am licensed under provisions of Chapter 9 ISSUANCE DATE
,HA w (commencing with Section 7000)of Division 3 of the Business and
¢ y �� BLDG. ELECT. PLG. MECH.
H w z Professions Code,and my license is in full fore e ❑ ❑ 11z o w- Dicensy,.Cl;risy `Lie Numhe
o y H Date 6 L C ntractor
'a m Q ¢ OWNER-BUILDER DECLARATION BUILDING PERMIT
S o i v INFORMATION
X 5 LL w 1 hereby affirm that I am exempt from the Contractors License MISC.- REFER TO ORD
LL ygLUATION $/FT.
LL O ¢ Law for the following reason.(Sac.7031.5,Business and Professions
t Leo Code:Any city or County which requiresapennit tomnstruct,alter, PERMIT ISSUANCE 10.00
¢ ¢ ¢Q improve,demolish,or repair any stnmlure,prior to its issuan Ce,also ELEC.CONTR. LIC.NO. ELEC.
w- 0 a requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
he is licensed punuam to the provisions of the Contractor License Jd ` Q /
Hii
Law(Chapter 9(commencingwith Section 70000ofDivision 3 of the
¢ Business and Professions Code)or that he is exempt therefrom and QTV. PLUMBING PERMIT FEE
f i o
It H e the basis for the alleged exemption.Any violation of Section 703L5 STORIES TYPE CONSTR.
d ; �2 by any applicant Ems permit subjects the 0).): um macivil penalty ALTER-DRAIN -WATERIEA.) 5.00
of not more than loo hundred dollars(my em:
❑ I,as owner the properly,or my employees with re is as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their solecompensation,rif . fwill(S the work,and the structure is not
Code-T or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AR EA,CON D. 5.00
Cole The Contractor's License law does not apply to an owner of
properly who builds or improves Thereon,and who does such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve
ments are not intended or offered for sale.IL however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is Sold within one year of completion,the owner- GAS SYSTEM O ER 4 IEA.) 2.00
builder will have tile -EA. -e burden of proving that he did not build or im- y BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. RES IND CON PB Omer
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ED ED
licensed Contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves tlmreon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts forsueb projects with a contractogs)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I:ml exPea empt under Sec. .B.&P.C.lin this WATER HEATER W/VENT 6.00 `
OwnerDate WATER SYSTEM S.00 ACC.DATE ACG FILE NO.
WORK ERS'COMPENSYTION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm (bat h e' certificate of consent to self-insure,
or a certificate of Wer mpensation Insurance,or a certified ZONING ENG.SITE NO.
copy memof(Su 3 .0 .
Policy No. Cor a
❑ Cerllfed copy is r tlrushed. FIRE$PRINK ENERGY T 24
Z Z� ❑ Certifed copy s led with the city inspection division. MISC.- REFER TO ORD.
O Applicant v N YEJ N
~ rn PERMIT ISSUANCE 10.00 0
CER'I'IFICA'I'Ii OF EXEMPTION FROM WORKERS' FLOOD ZONE A.L.U.C.
1
L COMPENSATION ,RANCH PLG.CONTR. LIC.NO. PLG. /� ❑ ❑ ❑ ❑CL 0 (This section need not be em e d if the permit is for one TOTAL Y N V N
11 D Z hundred dollars(S 100)or less-)
U O I certify that in tile performance ( herk w u h this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
3 L F mit is i3ed,I shall no(crop oy a -r. I cr so as to
_O w hemp1�.s lee m Wco v C nt r r 11 s alifurniu.
I a Date.Q ApplicantALTER OR ADD TO MECH. 5.00 BUILDING
/ } N NOTICE 'TO APPLICANT: If a making(hi. ertl ma a .x-
( ? emption,you should become object to the Workeri Compensation 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=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IQOOOC.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for 'EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lenders Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
1 certify t I have read this application and slam that the above VENTILATION FAN (SINGLE) 4.00 (�
• infonw(i s mrrecl. 1 agree m comply with all it,and county PLUMBING
ordinan 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 upon the BOILER-COMP (Over 100.000 BTU)SEE FEE SCM. MECHANICAL
abOvc l6 L. ed pro for inspection purposes.
(W / Tee to c, demnify and keep harnilras the City of MISC.- REFER TO ORD.
Caper IT agai bit'es,judgments,ls, costs and expenses which CONST.TAX
may IT ny y cc a against said City in consequence of the PERMIT ISSUANCE 10.00
ra I it s, MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
ignuturg I ppiwnt/Contractor Dole
// INSPECTOR COPY