6031 - 1
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATIONPERMIT NUMBER
BUILDING APPLICATION & PERMIT _ _ 6031
ADDRESS BUILDING -ELECTRICAL-PLUMBING -MECHANICAL
1 I C�
11WNERS PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE-
cONrHAc7Dms
E OUTLETS-SWITCHES'--'RECEP 5.00/1.00
NAMQ
LIC,NO.�J J LIGHTING FIXTURES 5.00/1.00
_ ADDRESS TORS PPLIANCES-RESIDENTIAL 4.00
r - AQ w\103A PHON PANELS 5.00 DATE OF APPLICATION
ARCHITECT - SIGNS 6.00 PIAN CHECK FEE P.C.NO.
OR
ENGINEER
• uc.Na. SIGNS TRANS. 3.00
ADDRESS eruct SPECIALCIRCUIT 8,00 PERMIT VALIDATION
• 'ZIF EMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH. -
ADORESS
SERVICE CHANGE 10.00 �tG
0 0 o LICENSED CONTRACTORS DECLARATION r /"�
U I hereby ifforn that I am licensed under provisions of Chapter 9 J 11T 0--( ID ISSUANCE DATE
N G w (commencing with Seclion 7000)of Division 3 ofthe Businessand BLDG. ELECT. PLG. MECH.
H Professions C.deed my license is in full force� �ffec``
z O m - /License Cl ss E�..�- -� Lic.Number aa� ``'' u� ❑ ❑ ❑
o z H o Date�_,JA_Slf r_Contractor_F -
H x f ` BUILDING PERMIT
¢ rc ¢ OWNER DECLARATION FORMATION
MISC.- REFER TO ORD Cit Qf.
C 6JnArfinhN
w3 r i hereby affirm that 1 um exempt frons the Contractor's License
a. o¢ Law for the following reason. 7031.5,Bushossand Prol'essioos PERMIT ISSUANCE VALUATION $/FT.
ris v, Code:Any city orcounty which requires a permit to construct.alter, 6.00 �/ 6 �O
¢ ¢ Q Q improve,demolish,or repair any structure,prior l0 its issuance,also SLED.CONTR. LIC.NO. ELEC. /
O u requires the applicant for such permit m file a signed statement that TOTAL PERMIT TO
d w Co he is licensed punuam m the provisions of the Contractor's License
F z i
Law(Chapter 9(commeneingwlth Section 7000)of Division 3 ofthe
¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT PEE
¢ H p the basis for the alleged exemption.Any violation of Section 7031.5 STORIES Ty PE CONSTR.
of by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars($500).): e_i}V 40<,
❑ I,as owner of the property.or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.CHU RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Set, 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 q SEN
Code:The Contractor's License Law does not apply to an owner of, e2
property who builds or improves thereon,and who does such work FIXTURES.-PER TRAP 4.00 50.FT.FLOOR AREA TOTAL ACREAGE
Himself or through his own employees,provided that such improve- -EA.SYSTEM-I INC.4 OUTLETS 4.00
I� mems are not intended or offered for sale.If,hw
oever:thc.building GAS
or improvement is Sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden pf proving that he did not build or int- RES IND CON PB Omer
prove for purpose of sale.. I NDUSTRIAL WASTE INTER. 20.00 El El El El❑ 1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Profeoions Code:The Cornractor's License Low docs not apply.
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 conlmetons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA:200ft/8.00 TRACT NO. PARCEL NO.
❑ lamexemptunder Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00 -
rcason
Owner Dam WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COM PENSATION DECLARATION WATER TREATING EQUIP. 4.00 '
I hereby affirm that I have a certificate of consent to self-insure.
or a ttrificute of Workers'Compensation Insurance,or a certi led ZONING ENG.SITE NO.
copy Ihereof(See.3800.Lab.C.I {,�,, M ` ,. C1
Policy No. Company I I VV(_-1 l-,V 7-1l-Y.J�
O" ❑ Cenified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certi{:cd_ ofd I I wl the city inspection division.
Apphcarit-L.NxL-7t.--YI Is 15MISC.-', REFER TO ORD. y ❑ N❑ Y ❑ N❑
N. CIiRI IFICATE 01:EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOOZONE D.C.A.L
Lu >_„ COMPENSATION INSURANCE PLG.CONTR. ❑C.NO. TOTAL ❑ ❑ ❑ ❑
6. ❑ ('Thi, coin, need not be completed if the permit is for one y N y N
D Z hundred dollars(5100)air less. -
U O 1 coolil'y that in the performance of the work for which thio Per, CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is Isxled,I shall nut employ.any person in any mannonuo as to -
U beconm subject to the Workers'CompcmWlon Laws of Calil'omiu:
U w Date Applicant - BUILDING .C'd SZ
a ALTER OR ADD TO MECH. 4:00 d
} N NOTICE','1'0 APPLICANT': If,after making this Certificate of fix- ,
? emptlon,you should become subject to the Workers Compensation 'APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such prosi,ions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10A00C.F.M.) 3.00
.CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a Construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00 '
the perfannance of the work for which this permit is issued(Sec. MICROFILM
3097;Cis.C.). H EATING UN IT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address ess HEATI NG UNIT(OVER 100,000_B.T.U.P.50 ELECTRIC
I certify that l,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 countyPLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP 13 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the. BOILER-COMP (Over 100,o0OBTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes. _
,(We) agree to,save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cu ertmo against liabilities,judgments, costs and expenses which CONST.TAX
ay any way accrue unnst Said City inconsequence of the PERMIT ISSUANCE 3.00
rant g of this p MECH.CONT. LIC.NO. MECH.
�� OTAL r - TOTAL S
- elure o lean[/Contractor Date
OFFICECOPY