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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
PERMIT•NUMBERBUILDING
- ^ ,j
AooaEss p ,.
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
OWNER '$
-PLAN CHECK VALIDATION
NAME
_QTY.
f'J ,PHONE
ELECTRIC PERMIT FEE
'
NA.L ACTORS
OUTLETS-SWITCHES-RECEP 10.00/1.00
DI -0 Al UC.No. a't'/'y03
DATE OF APPLICATION
LIGHTING FIXTURES 10.00/1.00
CONTRACTOR's
ADDRESSDRESS-
lle3aa ((%000 HONE 397-oQ
APPLIANCES - RESIDENTIAL .4.00
PANELS - 10.00
ARCHITECT , Ci 3b ]� L -
oR
ENGINEER
LIC.NO.
-
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
...-.
SIGNS TRANS. 3.00
AARCHDDRESS ENG'
Z11
SPECIALCIRCUIT 5.00
PERMIT VALIDATION
,nk,
TEMP. METER OR POLE INS. 20.00
ADDRlE ssT��p xfr�[j �/ �''lJ<JYJD' vi�D
MOTORS SEE FEE SCH.
LO TDS Sn.5
SERVICE CHAN GE 20.00
J'^C'
"r
' LICENSEDCONI'RACT'ORS DECLARATION
1 hereby affirm that 1 am licenwd under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Rusinessund
Professions Codc. Std m license is in full force and effect
License Class _`/� Lie. Number �
'v QILI ANCE DATE
-
BLDG.
El-,
-EBECICI
rU'PLG. MECH.
J❑ � ,
Dutc_f Z/?,gin Conlractor.�QjryL�'
BUILDING PERMIT
INFORMATION
" OWNER -BUILDER DECLARATION
1 hereby affnd that I am exempt from the Contractor's License
Lawlor the following reason. (Sec. 7031.5, Business and ProfessionsVALUATION
Code. Any city or county which rejuiresa permit to construct, alter,
improve, demolish, or repair any structure, prior 10 its issuance, also
requires the applicant for such permit 10 file .signed statement that
he is licensed Pursuant to the provisions of the Contractor's License
/
nA1SC. -'VV
EFER TO ORD
$/FT.
-
P VITIS A `t 10-00 Q
ELEC. COrvY
\
IC. NO.
I
ELEC.
TOTAL
PERMIT TO
}
lfT LU
ING PERMIT FEE
Law (Chapter 9(commencing with Section 7000) of Division Sot the
Business and'1h.I.sions Cede) or that he is exempt thcref,,,qqqm and
the basis for the alleged ecemplion. Any violation of Sectio3L5
STORIES
TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civi p mBy
of not morethan fivehundred dollar,($500).1:
TE RAIN & E TER IEA.) 5.00
❑ I, as owner of the property, or my employees with "es as
their Sole con pensalion, will do the work, and the store it Is not
BACK LOWIS T T ICE 4.00
OCC. GROUP
RES. UNITS
DRAT -FL R, R F, REA,COND. 5.00
intended or offered for sale (Sec. 7044, Business vol T I c cions
'
Code: The Contractor's License Law does not anplY to an owner o
property who builds or improves thereon, and who does SUcI+�..!
himself or through his own employees, provided that such Impr v
ments are not intended or offered for sale. If, however, the b0ild t g
Is
FIXTU - R R PJ S.00
SD. FT. FLOOR AREA
• TOTALACREAGE
'
I
GA . S 7E - 1 INC.40UTLETS 6.00
or improvement is sold within one year of completion, the ow
builder will have the burden of proving that be did not huild u t n.
prove for purpose of sale.).
❑ I, as owner of the property': am exclusively' cwnru-ting with
G VSTEM -OVER 4 (EA.) 2.00
BUILDING USE .
RES IND CON PB , Omer
❑' ❑ ❑ ❑ ❑
WA E.
D T I LWASTE INTER. 30.00
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code The Contractor's License Law does not apply
to an owner 01Property who builds or improves thereon. and who
L S IN - 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
-
L WN SP INKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a ronvactor(s) licensed pursuant to
the Contractors License Law.
SE ER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO:
❑ lam exempt tender Sec.-, R&P.C. for this
WATER HEATER W/VENT 6.00
reason
Owner _ Dee
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE N0.
WATER TREATING EQUIP.. 5.00
WORKERS'COMPF..NSA I' ION DECLARATION
'
1 hereby affirm that I have a ecrlific.ticul .....sent to self -insure,.
or a cerldeate of Workers' Compensation Insurance, or a certified
c p hereof(See3800, Lab.C.).
uT�nY-�ed,
ZONING
ENG. SITE NO.
F
FIRE SPRINK -
Y ❑ N ❑
.ENERGY L24
Y ❑ N❑
ruffed copy is
❑ rliflcd coop is, filed furnished.
Aeanl ificd copy is Ince wish the city inspersion division.
�p7
MISC. - REFER TO ORD.
CERTIFICATE OF I XEMPT ION PRoM WORKERS'.
PERMIT ISSUANCE 10.00
FLOODZONE
A L.0 c.
PLG, CONTR. ,LIC. NO.
PLG.
TOTAL
' COA1PFNSATION INSURANCE -
(This section need net be completed if the permit 1s far one
Y ❑ IN E3
Y ❑ N❑
hundred dollars (b 100) e r leu .)
'1 certify that inthe pcHurmanee of the work for which this tier-
mit is issued, I shall not employ any person in any manner so as to
QTY - MECHANICAL PERMIT FEE
-
FEE SUMMARY
becomesubjecttotheWorkers'Compensation Laws of California.
Date Applicant
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, attic, making this Certificate of Ex-
emption, you should become subject to the Workers' C'onipensalion
APPLIANCE 5.00
HECKprovisions
of the Labor Code, you must forthwith comply with
such provisions or this permit Strait he deemed revoked.
AIR HANDLING UNIT (TO IO=C.F.M.) 4.00
AIR HANDLING UNIT(OVER'10=C.RM.) 6.00
C FEEI
fiBUILDING
CONSTRUCT ION LENDING AGENCY
hereby affirm that there is a construction lending agency far
EXHAUST HOOD (WITH DUCT) 5.00
lite performance of the work forwhich thispermit is issued (Sec.
Civ.C.). -
Lender's
FILM3097.
-
HEATING UNIT(TO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER 100,000 B.T.U.)9.50Lenders
RIC'
Address
Addr
I certify that 1 have read this application and state that the above
VENTILATION FAN (SINGLE) 4.00
..
information is correct. I agree to comply with allcity and county
ordinances and state laws relating to building construction, and
PLUMBING.
BOILER- COMP (3 H.P. or 100,000,B.T.U.) 6.00
BOILER -COMP lover 100.000 BT) SEE FEE SCH.
MECHANICAL
hereby aullorve representatives of this city to enter upon are
above-mentioned property for inspection purposes:
MISC. - REFER TO ORD.
(We) agree 10 save, indemnify and keep hamrless the City of
ino against liabilities, judgments, costs and expnses whicht
any way accrue against 'd City 'consequence of the
TAX
PERMIT ISSUANCE 10.00CONST.
"gof
6rpyL
this per ij.
J. 3-
MECH, CONT. LIC. NO. a
MECH.
TOTAL
TOTAL `f
tgnature of Applicant/Cont, ctor Date -
OFFICE COPY