8302 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTI FICATION PERMIT NUMBER
ADDRESS %APPLICATION & PERMIT 8302��
aDDRE55
+r - 20400 M8Y18II1 BUILDING-ELECTRICAL-
PLUMBING'MECHANICAL
OWNER'S QTY. `y PLAN CHECK VALIDATION
NAME SYVA / ELECTRIC PERMIT FEE
vwOrvE
CONTcroRs
NAME UTLETS- ELECTRIC
10.00/1.00
NAME �f. �1 1
LIC.{Lt. O`4V1 LIGHTING FIXTURES 10.00/1.00
rUNTFACTOR's APPLIANC12S'RESIDENTIAL 4.00
aoDREss r 417• -
�.. b PRONE �0 PANELS 10.00 DATE OF APPLICATION
A T CT / PANELS (OVER 200 AMPI 20.00 PLAN CHECK FEE
OR P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG. - SPECIAL CIRCUIT_--," 5.00 PERMIT VALIDATION
-• - - - - -- -- -ZIP FEMP. METER OR POLE INS. _20.00
ADr
Sns MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
o o LICENSEDCONTRACTORS DECLARATION TEMP.POLE 30.00
a
v U I hereby affirm That I am licensed under provisions of Chapter 9 ISSUANCE DATE
,HA G vNAi (Commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
Professions Code,and m license is in full force and effect.
z 0 y_ �p License Class r.-'+b Y Lic.Number ' �- _ ❑ ❑ ❑ ❑
D Z H ,p/ UatC '.{��COntraclD r� '�
BUILDING PERMIT
w u OWNER-BUILDER DECLARATION INFORMATION
A O a MISC. REFER TO ORD
w 3 LL 1- 1 hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
H LL O a Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requiresa permit to construct,alLL•q 2
aa Q p improve,demolish,or repair any structure,prior to its iss'uamco,also ELEC.CONTR. LIC.NQ ELEC. / d
6 Oo u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
u w m he is licensed pursuant to the provisions of the Contractor's License M�Q'�y
z i Law(Chapter 9(commencing with Section 7000)of Divisiun3of the r r
i o Business and Professions Code)or that he is exempt therefrom arid QTY. PLUMBING PERMIT FEE f"/ (a' J A i• _
M o the basis for the alleged exemption.Any vi.Imio.cf Section 7031.5 STORIES TYPE CONSTR.
A . _ by any applicant for a pennit subjects the applicant to a civil penally ALTER-DRAIN -WATER (EA.) 5.00
of entrance than five hundred dollars($500).):
❑ 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 st nature is not
intended or offered for sale (Sea 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 '
.Code The Cuntraetor's License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 So.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve
meats are not intended proffered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6,00
or improvement is sold within one year oIcompletion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will hove the burden of proving that he did mat huild or ire
prove for purpose of Sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON" PB Omer
t 0 I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors m construct the project(Sec 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs 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 o contmcloKs)licensed pursuant to SEWERSANITARY STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
0 lam exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACG FILE NO.
WORKS RS'COMPE NSATION DECLARA'ITON WATER TREATING EQUIP. 5;00 2
I hereby dfrm that I have a certificateofconsent toself-insure: -
or a certificate of Workeri Compensation Insurance,ora certified \ ZONING ENG)SITE NO.'
copy thereof(See.3800 Lah.C.I -
O -, 'nlicY No B-S - 4r7unY
O Cetc mYohcovhyf-uhl:t} G,HFIRE SPRINK ENERGY T-24'
z Z Certi�'iad copy is flW.wttpyhetY inspeclio dixision. ,
O A( icCe ✓•a c tin.. x•K ^J� MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
T CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.G
LU > COMPHNSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d
This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y'❑ N❑
z hundred dollars 1$1001 or less.)
U O 1 certify that in the perforntunce of the work for which this per. DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL h mit is issued,I shall not employ any person in any manner so os to
0U become subject to the Worker Compensation Laws of California. BUILDING $v
D, Date Applicant ALTER OR ADD TO MECH. 5.00
>_ 0NOTICE TO APPLICANT /if,after making this Certificate of Ex
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK d d7
provisions of the LaborrCode, you must forthwith comply with FEE O��J AIL
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE 5v
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 6.00 MICROFILM
L097,Cender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify Ota,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
uNinanmes and state Taws relating to building construction, and BOILER-CDMP(3 H.P.or 100,000 B.T.U.) 6.00
hcrcby amhorixo repres,rdatives of Ibis city to enter upon the BOILER-COMP 00ver 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of misc.- REFER TO ORD.
Caertin0 against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against.said'City in consequence of the PERMIT ISSUANCE 10.00
granting of this per Oi IMECH.CONT. LIC.NO. MECH.
�pt Xt i TOTAL TOTAL
S toe AIsplcan Co o ate
INSPECTOR COPY