18384 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY v
.,,BUI LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT 1 ��
AD RE55 �L` 1 -
�OIooS 4Ax�NEO fO• BUILDING-ELECTRICAL-PLUMBING -MECHANICAL 1
84 .
OWNER'S K� -- PLAN CHECK VALIDATION
NAME����!! �"�A//�/�/ t���w (/�j/� QTY. ELECTRIC PERMIT FEE
. (CTO a,�rr-V Y,/I� PHONEi I�{�1 - y�� •• -
NAME
CONTRACTOR UTLETS-SWITCHES-RECEP 10.00/1.00 JY/
NAMEr /,�• / `
' vG�WW LIC.No. LIGHTING FIXTURES 10.00/1.00 '
CONTRACTORSPPLIANCES-RESID
(osy{� ENTIAL 4.00
ADDRESS ww• �•�p'�y
WGPHONE%' PANELS 10.00 DATE OF APPLICATION
ARCHITECT
OR �iAWilleeWe�Q BIV PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
-
GINE
j D N SIGNS TRANS. 3.00
ARCH OR ENG. PERM T VALIDATION
AD RE's C p � . SPECIAL CIRCUIT 5.00 /f1A� P
EMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDREs
s ss ,
S ar Q R. .7SERVICE CHANGE 20.00 ,
woo LICEN'SE'D CONTRACTORS DECLARATION - -
a u c' 1 hereby'affirm that I am licensed under provisions of Chapter 9. - SUANCE DATE
y Z -A (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F ora z Profcssions COI ILI my license is in full(orp(fp
0 o m - Licm Lic.Numbc -/Er ❑ ❑ ❑
9 °w Dmu Contractor '
a x f .BUILDING PERMIT
¢ ¢ w ¢ OWNER-BUILDER DECLARATION
O. INFORMATION
X ;LL H I hereby'affirm that I am exempt from the CuNmctor's License MISC.- RD VALUATION S/FT.
HLLoJ' Law for thefollowing reason(Sec.7031.5.Businessund Professions PERMIT ISSUANCE 10.00
y} Code:Any city or county which requiresapermil toconsoucU alter, ELEC.CONTR. LIC.N0. �) O O
¢ ¢ ¢o improve,demolish,or repair any structure,prior to its issuance,also ELEC.
ia -o¢ requites the applicant for such permit to file a signed statement that TOTAL R IT TO
u w m he is licensed pursuant to the provisions of the Contractor's License - j� �
r z r Law(Chapter 9(commencing with Section 7000)of Division of the �, Q���
- ¢ Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE iC�/ AJ(7
¢ r,o the basis for the alleged exemption.Any violation UfSection 703 L5 . STORIES TYPE CONSTR.
n ; W by any applicant Ivor a permit subjects the uppl[cant,to a civil penalty. ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more thou five hundred dollars(S500):):
'
0 I,as owner of the property.or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure w not -
intended or offered for sale (See 7044. Business and Prolessions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 '
Code:The Contractor's License Law it....not apply to an owner of -
-"I property Who builds Or ltopfoses thereon,and Who does such work FIXTURES-PER TRAP 5.00 SD.FT.FLOOR AREA TOTALACREAGE
himself re Ov intended
his own employees,provided that Sade improve- .
humus are thmu, orofferedemplo employee,,
or Provided
thaer,lhebui Wing GAS-EA.SVSTEM-11NC.40UTLETS 6.00
orpor
improvement is sold within one year of completion.the owner- GAS-EA.SYSTEM-OVER 4 (EA,) 2.00 BUILDING USE
builder will have the burden o(powing that he did not build or int- RES IND CON PR Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,usowncr of the property.um exclusively contracting with ❑ ❑ ❑ ❑ ❑
licenud contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5A/.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does 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 contmetorts)licensed pursuant to
. the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. . PARCEL NO.
❑ 1 Bmexer I underSce. ,B.&P.C.forlhi, WATER HEATER W/VENT 6.00 -
Owner Date WATER SYSTEM 5.00
ACC.GATE ACG FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. '5.00 -
I hereby affirm that I have certificate of consent to sell-insure, ZONING ENG.SITE NO.
• or'a certificate I f Workers'Compensation Insurance,or v colitied ,
Copythcri S�m1800,Lan,:)/ �:f f
Policy No- O Company_{l M17
O ❑AJt
c yf000hed. - FIRE SPR INK ENERGY T 24
z Z f( Cy I city inspection division.
p Applica _ MISC.- REFER TO ORD. v ❑ 'N❑ v ❑ N❑
y CPI?OP EXIT PITON PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.ULC.
LU OMPENSATION INSURANCEPLG.CONTR. LIC.NO. PLG, v❑ N❑ Y NEICL o ('Phis section need not be completed if the permit is for one TOTAL
Z hundred dollars IS 100)or less.)
U O 1 certify that in.the performance of the wick for which this per- QTY MECHANICAL PERMIT _ FEE" FEE SUMMARY
LL F- mit is issued,I 'hull out employ any person in any manner so os to _
U hccnlresurrect to the Workers'Conlpensmlon Lows of California. 0o
�.W Doc Applicant ALTER OR ADD TO MECH. 5.00 BUILDINGBILL
_
} to NOTICE TO APPLICANT: If after making this Certificate of Ex-
? emption,you should become Subject 10 the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U
such provisions or thispermit shut[be deemed revoked_ AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
'.CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10PMC.F.M.) 6.00 i SEISMIC FEE I•ZO
1 hereby affirm that there is a construction lauding agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work Ivor which this permit is issued(See. MICROFILM �-
3097,Cir.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender',Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct.1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building c nstruction. 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 SCH. MECHANICAL
above-mentioned property for inspection purposes.
(Wo) agree ID save, indemnify and keep harmless the City of - MISC.- REFER TO ORD.
pertino against liabilities,judgments.'costs and expenses which CONST.TAX
IT in y accuse against mid City in consequence of the PERMIT ISSUANCE 10.00
g of, I. MECH.CONT. LIC.NO. MECH.
8.7 8 ��•an
Signator ol'Applicun -omtractor TOTAL TOTAL
Dafe -
OFFICE COPY