2278APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONJ,!
BU LDI NG PROJECT 1 DENTI FICATI ON
APPLICATION &PERMIT
PE t MBER
8
BUILDING
ADDRESS
-�G1 Z
�'J�O
BUILDING -ELECTRICAL- PLUMBING= MECHANICAL
v
PLAN CHECK VALIDATION
OWNER'S -
NAME-
PHONE Zss `139b
OTY. ELECTRIC PERMIT FEE
NON', ERAcioRs
OUTLETS - SWITCHES -RECEP 5.00/1.00
'I' E�HJ Llc. No.'s p Z
LIGHTING FIXTURES 5.00/1.00
ADDRESS Fs -
APPLIANCES - RESIDENTIAL 4.00
`Zu PRONE -V
PANELS 5.00
DATE OF APPLICATION
ARCHITECT
OR
ENGINEERA ��,a •S ,E
J�r 1v LIC, No,
SIGNS 6.00
PLAN CHECK FEE P.C. NO,
-
SIGNS TRANS. 3.00
ARCH. OR ENG, '-
ADDREffi 11U
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 15.00
��
_ N ZIP
AS
ADDRESS
Y 2� SY ,•
MOTORS. SEE FEE SCH.
SERVICE CHANGE 10-00
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and,
Professions Code, and py license is in full is an -f- A
LicenS$.,Class_ ,-��.O- Lie.\umber d L
Dale tj'Z 4! Contractor -,1982
-r
ISSUANCE. DATE
-
ULU"
I ELECT.
E
PLC.
�
MECH.
�{
Qv/e'1
(�� ) 'I
BUILDING PERMIT
INFORMATION
' OW'NIi R-BUILDfiR DECLARATION
I hereby affirm that I am exempt from the inessacmr'S License
Law for thefollowingnty wh(See uiresa:erminesand Professions
Code: Any city or county any Structure putout its issuance, alser,o
improve, demolish, or repair such permit rt tofileprior sign dsiatche t. a6o
he Ul Sic Rled purse ltt t the rovist0 oftaSContlactorIs encthat
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9 (commencing with Section is ext e 1 Division 3 of the
Business and Code) or that heir exempt and
MISC. - . ER TO ORD
PERMIT ISSUANCE 6.00
-
VALUATION
$/FT.
ELEC. CONTE. LIC. NO.
ELEC.
TOTAL
PERMIT TO
MLs G �.
_
QTY. 'PLUMBING PERMIT FEE
STORIES
TYPE CONSTR. `
eca-from
the basis for the alleged exemption. Any violation of Section 7031.5
he alleged
by any applicant for e permit subjects the applicant t.arivilpenBlty
of not more than five hundred do1W¢($500).):
- ALTER -DRAIN & VENT -WATER (EA.)4.06
❑ I, as owner of the property, or my employees with wage$a,
❑Ieir sole compensation, will do the work, and and the structure Is not
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
intended of offered for sale (Sec. 7044, Business and Professions
Code The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who doer such work
himself or through his own employees, provided that such improve-
ments are not intended or offered for sole: If, however, the budding
FIXTURES - PER TRAP 4.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM -11PJC. 4 OUTLETS 4.00
or improvement is sold within one year of completion, the owner-
builder, will have the burden of proving that he did not build or im
prove for purpose of sale.)
❑ 1, as owner .l' the property, am exclusively contracting with'
GAS - EA. SYSTEM -OVER 4 (EA.) 1.00
BUILDING USE
RES IND CON PB Omer
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
licensed contractors to c ...Truer IIIc pnajtcl (See 7044, Business
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- 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 IEA,) 1.00
ASSESSORS PARCEL NO.
_
contracts for .such projects with a contrnetons) licensed pursuant to
the Contractor', License L.W.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
❑' lam exempt under Sec. .B.&P.C. for this
teasOn
-
WATER HEATER W/VENT 4.00'
Date Owner
WATER SYSTEM 4.00
Aec. DATE
ACG FILE NO,
WATER TREATING EQUIP. 4.00
WORK E RS' COMPENSATION DECLARATION
I hereby affirm thm 1 have a ccnihcah, III CMnecut ¢s se1G'ntsure,
or a certificate of Worker', Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof:. j100, Lab.0 ). ' 11
Policy No ompan1'�CNPTILA /--t'b+�•�t,-
-.
-
FIRE SPRINK
Y ❑ N❑
ENERGY T24
Y ❑ N❑
❑ Certified copy' is hereby furrishaL
iia QTtI py "-led 'ith .the city inspection dlvi...m
Applicant[ �'�"(I�S
MISC.- 'x REFER TO ORD.
CERI'IIICA'I' E 017 Iz X[:.'slPl']ON PROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.U.C.,
PLC. CONTE.LIC. NO.
PLG.
TOTAL
COMPENSATION INSURANCE
(This section need not be completed if the penult is tlu one
Y [:] N ❑
V F] N ❑
hundred dollars IS 100) or less.) -
1 certify that in the performance of the work for which this per.
mit is issued, I shall not employ any person in any Trusser V, as to
OTY MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to 111, Workers' Compensation Laws of California.
Date - Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Es-
ALTER OR.ADD TO MECH. 4.00
APPLIANCE 4-00
PLAN
entption, you should become subject'[. the Workers'Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
EEE -
AIR HANDLING UNIT (TO 10,000QF.M) 3.00
AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00
SEISMIC FEE
CONSTRUCIION LENDING AGENCY .-
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 2.00
the performance of, the woik for which this peril is issued (Sec.
3097. Civ.C.L
MICROFILM
H EATING UN IT (TO 100,000 B.T.U.) 4.00
HEATI NG UN IT (OVER 100,000 B.T.U.)7.50 d a
ELECTRIC
Lender's Nance AJOf�E
Lender's Address
I certify that I have read this application and "amtl'a the about
information is correct. I agree to comply with all city and county
orhmoces um state laws relating to'buildieg construction, and
hereby authorize representatives of this city to enter upon the
above-mentioned properly for inspection purposes.
VENTILATION FAN (SINGLE) 3.00
-
PLUMBING
BOILER-COMP(3 H:P- or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100,000BTU1SEE FEESCIT
MECHANICAL
MISC. -- - REFER TO ORD,
_
CONST. TAX
(We) agree to save, indemnity and keep harmless the City of
TTIrRro against liabilities, judgments, costs and expenses which
,,! t any way a cnue against Said City, in conse,mncc of the
g anf g fthisp mu.
PERMIT ISSUANCE 3A0
MECH. CONT. LIG NO.
MECH. py
)this
8 R 5
'�-O 30 2
TOTAL Y
TOTAL
Sig i ontr or Dam
I OFFICE COPY