7159 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
:BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
7� 59
BUILDING APPLICATION & PERMIT
ADDRESS /
/ V3SY LIi�L/) Ca�K� BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OwNEHS PLAN CHECK VALIDATION
�( NAME ` OTY. ELECTRIC PERMIT FEE
GA1� J ?/�/a(/.11< PHONE � -��4
NAMERACTons // OUTLETS-SWITCHES-RECEP 5.00/1.00
9`04(f ctrTl
l Elfl"-114 &V TVLN
IC. O.v 411/!(M'3 LIGHTING FIXTURES, 5.00/1.00
! CONTRACTOR 5"4,w Ju S/F PPLIANCES-RESIDENTIAL 4.00
`F ADDRESS ^C p
874c )u1F!?N L /�✓r J / PHONE `V 7 Q/// PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00
ENGINEER PLAN CHECK FEE P.C.NO.
OR
uc.NO, SIGNS TRANS. 3.00
ARCHESS REND. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP frEMP.METER OR POLE INS. 15.00
APPLICANT ADDRESS MOTORS SEE FEE SCH.
A
SERVICE CHANGE 10.00
o a LICI?NSED CON"FRACfORS DECLARATION
2 v U I hereby art!.... [,at 1 am licensed under PoWblunsof Chaplet 9 ISSUANCE DATE-
z p1 (cunvnenctngwith Section 7000)of Division 3 of the Business mW
y BLDG. ELECT. PLG. MECH.
H w z Professions Cod d n license is in full fore- n�l ee�. t ❑ ❑ ❑ ❑
z o m Li¢ns Cla' Lie.Number
o m t w Dae Conlmdor
1.
m ¢ ¢ OWNER-BUILDER DECLARATION BUILDING PERMIT
rc w< INFORMATION
K
o u w 1 hereby affirm than I am ex t from the Comrador's License MISC.- REFER TO ORD
3 u y P VALUATION $/FT.
Ha- Law mEthe l"Wowingreuson.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires permit toconsUucC.1eq 7 -40
0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIG NO. ELEC.
LLrequires the applicaut lilt Such permit to I He a signed statement that TOTAL PERMIT TO
u w m he is licensed pursuant to the provisions of the Contractor's License
r z a Law(Chapter 9(commencing with Section 7000)o f Division 3 oflhe PRi,< W/j 7$Q JR.,.i"
i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
M H o the basis for the alleged exemption.Any violation of Section 7031.$ STORIES TYPE CONSTR.
ra
ate _ by any applicant for a permit subjects the applicant to s civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars($500).1:
❑ I,as owner 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 stmdure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code:"fire Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.ET.FLOOR AREA TOTALACREAGE
himself or through his own employees.provided that such improv- -
mentsarenotintendedoroffered for sale.If.however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
pRolI.,Purposeofsulc')' INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB Other
C3 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(See 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License.Low does not apply
to an owner at property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contmctods)licensed pursuant to
lite Contmclor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
0 l am exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 4.00
poison
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSAT ION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate ofconsent to sell=insure. ZONING ora certiticate of Workers Compensation Insurance,or a certified ENG.SITE NO.
capy mercof-JS_ 0 Coi ItaRyC.t_5.ra�/3
Policy Net O�rrG Company
O' 1), Certified copy i5 hereby furnished FIRE SPRINK ENERGY T-24
Z z 0Certilic�s op s fled with the city inspection division.
O� Applin m .1 f) 9lt MISC.- REFER TO ORD. Y❑ IN Y ❑ N❑
O: T Cl:R'I'IP ICATE OI1 FXEMPIION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. V❑ N❑ YE] NE]
1'I'his section need not be completed if lire permit is for one TOTAL
hundred dollar,IS 100)or less.)
L) O 1 certify that to the performance of tine work For which[his per- OTV MECHANICAL PERMIT FEE FEE SUMMARY
1 ILL I- mit is issued,I shall not employ any person in any manner So as to
become subject to(he Workers'Compensation Laws of California.
Ow Ume Applicant BUILDING
a ALTER OR ADD TO MECH. 4.00
} rn NOTICE TO APPLICANT: If,after making this Certificate of IN-
z cntptiun,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
Provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,00DGF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000GEM.) 5.00 SEISMIC FEE
�-
I hereby If ire that [here is a construction rending agency for EXHAUST HOOD(WITH DUCT) 2.00
the ,Civ.nonce of tiro work for which this permit is issued(Sec. MICROFILM
3onde,*S .C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)7.50
Lender's AAJress ELECTRIC
I certify that 1 have read(his application and slate that(he above VENTILATION FAN (SINGLE) 3.00
• information is connect.1 agree to Comply with all city sad county PLUMBING
ordinances and State laws relating to building construction, and BOILER-OOMP(3 H.P.Or 100,000 B.T.U.) 4.00
hereby authorise representatives of this city to enter upon the BOILER-COMP (Over 10.00 BTU)SEE FEE SC". MECHANICAL
above-mentioned property for inspection purposes.
(We) agruc to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
CoveHino against liabilities,Iud ems, costs and expenses which CONST.TAX
may in way aecru gain said Cily in consequence of the PERMIT ISSUANCE 3.00
gm g his pet it [ MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL a/00
/ Signalurcof Applicant/Contractor Date - 0
INSPECTOR COPY