2069 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY �
BU I LDING PROJECT I DENTIF I CATION PEMlr ER
BUILDING APPLICATION &PERMIT 069
AVS6 BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
Iv
1,
J OWNER PLAN CHECK VALIDATION
rvnME _ OTY. ELECTRIC PERMIT FEE'
wlo�
CONTRACTOR'S
NAME / - OUTLETS-SWITCHES-RECEP 5.00/1.00
uc.No LIGHTING FIXTURES 5.00/1.00
, NRA Tons APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHON %�/G PANELS 5.00 DATE OF APPLICATION
ORC E SIGNS - 6.00 PLAN CHECK FEE P.C.N0.
ENGINEER
uc.NO. SIGNS TRANS. - 3.00 -
AARCHOR DDRESS ENG. SPECIAL(CIRCUIT .5,08 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 15.00 ,T
ADDRESS MOTORS SEE FEE SCH.
AS -
SERVICE CHANGE 10.007�{�
o O LICENSED CONTRACTORS DECLARATION
< u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
Ce a a (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r w z Professions Cot gpd�m license is in full fur- '� ❑ ❑ ❑
Z o w - Liccnsc ass J_ Liu.Numbed
o m E w Date Contractor_
St m s < I BUILDING PERMIT
¢ R w u OWNER-BUILDER DECLARATION _ INFORMATION
E: o A MISC.- REFER.TO ORD
w ;LL y I hereby affirm Iha1 I um exempt from the Contractor's License VALUATION $/FT.
F u o sr Law for the following reason.(Sec.703 1.5,Businessand ProfessionspERM1T ISSUANCE 6.00 t
Code:Any city or county which requires a permit to construct,alter.
aat¢ improve,denwlish,or ropuirany structure,prior its issuance,also ELEC.CONTR.-. LIC.NO. ELEC.
n w m u requires the applicant for such permit to file a signed.statement Iha1 TOTAL PERMITTO
he is licensed pursuant to the provisions of the Contractor's License Qf/ �
F z i
Law(Chapter 9(Commencing`^'ith Section 7000)of Division 3 o the !'� e.- •'
a Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
D the basis for the alleged exemption,Any violation of Section 7031.5 STORIES TYPE CONSTR.
a3�
by any applicant for a permit subjects the applicant o a Civil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00
Oftot tore than five hundred doll...(5500).1:
El I,as ownci of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00. OCC.GROUP RES.UNITS
their sole compensation,will do the work.and the structure is not
intended or offered for sale (Sec. 7044, Easiness and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,.nd who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself re of intended
his own employees.Provided that such improve- '
hients mself a ....amended oroempl employees,
sale.provided
that r.suhebuilding GAS-EA.SYSTEM-1INC.4OUTLETS 4.00
or improvement is sold within one year of completion,the owner- - GAS-EASYSTEM-OVER 4 (EA.) 100 BUILDING USE
builder will have the burden of provng that he did not build or int- . . . REE IND CON Pa ower
Prove for purpose of sale.).- I N DUSTR IAL WASTE INTER. - 20.00 ❑ ❑ El El El
I,as owner of the property',am exclusively Contracting with
licensed contractors to construct the project(Seo. 7044,Bus s LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS FARCE L NO.
and Pru fessions Code:"I'lie Contractor's License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 IEA.) : 1.00
contracts for such projects with a contrachado licensed punaant ro
it,,Contractor License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,11.&P.C.tier this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM- 4.00 ACC.DATE ACC FILE NO.
WORKERS'COMPENSA'[ION DIiCLARA'IION WATER TREATING EQUIP. 4.00 . -
I hereby affirm that I have a certificate of Consent Io Sall-in Ore, ZONING ENO.SITE NO.
or A ear}i¢ate of Workers' mpmts ti t saran e-ora c) tried
coyJ!
P 0 u
0Cetih
r ' cop y'Is lucre 'famiSlte FIRE SPRINK ENERGY T.24
z p Aq/'cant t c• cop . .f u' h c cit' i R'DO o . MISC.- R O'O Y [:] N❑ v ❑ N[]~ y %
PERMIT ISSUANCE 6.00 (J!� . .
ir ,CP TIE)CATEOF EXEMI'I'ION PRPNI W RKEBS' Citl,
LU �_ COMPF.NSd1'IONINSUR NC' PLG.CONTE. LIC.NO. FLOOD ZONE AL.u.c.
CL O ('Phis section need not be completed if the permit is for one TOTAL V❑ N❑ V❑ N❑
Z hu..dred dollars IS 100)Or to,, e -
U O 1 certify Ilial in the performance of fire work lot which this per- QTY. MECHANICAL PERMIT - FEE FEE SUMMARY
EL H mit is issued. I shall'not employ any person in any..tanner so as to
Q,U become subject it;the Workers Cum.croinion Laws of Culifonti..
ED D.IC A+ licant BUILDING
a 1 p - ALTER OR ADD TO MECH. 4.00
}'tA NOTICE TO APPLICANT: If,after making this Certificate OF Ex-
♦- 2 sorption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
.provisions of the Lanor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deelned revoked. AIR HANDLING UNIT(TO 10)000C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10SMC.F.M.) 5.00 SEISMIC FEE
I hereby :dflrrn that there is a conmot tion lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the pcdorvmnce of the work for which this permit Is issued(Sec. - MICROFILM
3097.Civ.C.). HEATING UNIT (TO 100,000 B.T.U.4 4.00
Lender's Name
Lender's Address HEAT,I NG UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify that 1 have read this application and stare that the above VENTILATION FAN (SINGLE) 3,00
Information is correct I agree to comply with all city and County PLUMBING
ordinances and state laws ri•latitig to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 • ��( D
herehy authorize representatives Of this City w Cnter Imes the BOILER-COMP (OVar 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection porpoises.
(We) agree 10 save, indemnify and keep harmless the City of MISC.- REFER TO ORD. -
Cuper.Roo against liabilities,judgments, costs and expenses hich _ - CONST.TAX
mIy in any way uun against said City in are of t c PERMIT ISSUANCE 3.00
gra 1 g of Itll permit.I` MECN.CONT. LIC,NO. MECW
TOTAL
TOTAL
s' to ¢ nI( ntr.otnr a ,.
OFFICE COPY