8390 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS 8390-^n 0
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL Q L1J `VI
PLAN CHECK VALIDATION
• NAME x u QTY. ELECTRIC PERMIT FEE/ PFONE V'/r'
kME OHS
CAME 10.00/1.00
uc.N LIGHTING FIXTURES - 10.00/1.00
N ACTOR PPLIANCES-RESIDENTIAL 4.00
A DRE56
PANELS 10.00 DATE OF APPLICATION
R ' PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.No.
ENGINEER
uc.No. SIGNS TRANS. 3.00
ADDRESS ErvGSPECIAL CIRCUIT 5,00. t PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS Nf?"J
MOTORS SEE FEE SCH. /�_C�
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 � � (�
U I hereby affirm that 1 am licensed under provisions of Chapter 9 IBSUANC DATE)
s, n (commencing with Section 7000)of Division 3 of the Business and¢ BLDG. ELECT. PLG. MECH.
H w i Professions and my license is in lull for e I fleet ❑ ❑ ❑ ❑
z O w - License Class Lie NumbeP
9 r °w Datc Contractor
a y ' BUILDING PERMIT
¢ a, n U OWNER-BUILDER DECLARATION INFORMATION
w ; LL m I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
F u o¢ Law for the following reason(Sec.7031.5.Business andProfessions PERMIT ISSUANCE 10.00 VALUATION S/FT.
Code:Any city.,county which fcquires a permit to comsto cl,alter,
Q Q Q 0 Improve.demolish,Or repair any structure',prior t.its issuance.also ELEC.CONTE. LIC.NO. ELEC.
O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
A w m he is licensed pursuant m the provisions of the Contractor's License
H'zQ
Law(Chapter 9(commencing with Section 7000)o'Division 3 ofthe
f 4 c Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
S, F p the basis for the alleged exemption.Any violation o(Section 7031.5 STORIES TYPE CONSTR.
a3 °� by:uiy applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars I S500)J:
r ❑ 1,as owner of the property,or my employees with wages as
s their'sole compensation,will do the work,and the structure is not BACKFLOW PROTECT.DEV ICE 4.00 OCC.GROUP RES.UNITS
'mens nded or offered for sale(See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code 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 SO,FT.FLOOR AREA TOTALACREAGE
• himself ments re Through his own employees,s Provided that such improv,
himself
not through
intended onemployeemlalLhowever.suhebuilding GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or inlprovennent is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 (EA) 200
builder will have the burden of proving that he did not build or im- - . - . .
BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 3000 RES IND CON PS Omar
❑ 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. 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 contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Ser,-,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner -Dat, WATER SYSTEM 5.00 ACC.DATE ACC.FILE No.
WORK ERS'COMPF.NSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby ulfirn that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'COmpensution Insurance,or a certified
4 Lp
copy Ihereo(ISec.380a -
Policy enc 00, ano
0 ❑ Cerilled 'opyishereby a is, FIRE SPRINK ENERGY T 24
Z 2 ❑ CerI led o y Is TO d w'th the city inspection division. MISC.- REFER TO ORD.
Q Applicant Y ❑ N❑ Y ❑ N❑
CC CBR'I'1171CAI'E OF EX F. ION FROM WORK fi RS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.UC.
W > COMPI NSAI']ON INSURANCE PLG.CONTE. LIC.NO. PLG.
Z
IT section need not be completed if the permit is for one TOTAL Y[:] N❑ Y❑ N❑
hundred dollars IS 100)or less.)
U O 1 cently that in the performance of the work for which this per. CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner S.as to
U become subject to the Workers Compensation Laws of California.
a DareApplicant ALTER OR ADD TO MECH. 5.00 BUILDING J ,J�
} to NOTICE 'f0 APPLICANT: If,after making this Certificate of Ex- J
? emption,you should become subject to the\Yorkers'Compensation APPLIANCE 5.00 PLAN CHECK -
orovisions of the Labor Code, you must forthwith comply with FEE
C..1 such sl
provisions or this permit wll be thinned r,vr,kcd. AIR HANDLING UNIT(TO 10=C.F.M.) 4,00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE .
1 h..clay Affirm that the is a c onitroctim, lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name �� HEG UNIT 100,000B.T.U.)0.50
Lender's AddressATINNT(OVER ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
im tioinc on n correct. I agree i comply with all city and county PLUMBING
ordinances is state laws re to c m building construction, anal BOILER-COMP I3 H.P.or 100,000 B.T.U.1 6.00
hereby iturth.i,e repro,cotrit ryes of this city to enter upon the BOILER-COMP(Over 100000 BTU)SEE FEE SCH. MECHANICAL
above-men I ned property for inspection purposes.
(WyJ ag � to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
CIL)c R o a Oma liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may n ny ay ace against mid City i consuq ucoce of the
gr f,h permi. MECH.CONT. LIG NO. MECH.
TOTAL TOTAL d0
t pile / Ir to '
INSPECTOR COPY