8728 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 8728
\,
ADDRESS
r104W MAZ�Oi BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
ONE
CONTRACTORS
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
AONTR crags
ADDAPPLIANCES-RESIDENTIAL 4.00
REss
PHONE PANELS 10.00 DATE OF APPLICATION
ORCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.No. SIGNS TRANS. 3.00
L.
ADDRESS ENC. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP FTEMP.METER OR POLE INS. 20.00
AMOTORS SEE FEE SCH.
ADDDRESSDRESS
SERVICE CHANGE 20.00
w09 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
¢U v 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y a T (commencing with Section 7000)of Division 3 of the Business and
BLDG. ELECT. PLG. MECH.
>F w z Professions Code,an n license is in full force and effect ❑ ❑ ❑
¢ o m - License Class- LIC.Number
wr w Data�...,,,/ilo _Contractors_.
a S, < .7�'(+7 I
¢ a OWNER-BUILDER DECLARATION BUILDING PERMIT
a o d INFORMATION
X g aF., 1 hereby al firm that I so exempt front the Contractor's License MISC.- REFER TO ORD
F ¢ 0 < Law for lhc(ollowing reason, 7031.5.Businessand Pr ofcssions PERMIT ISSUANCE VALUATION S/FT.
Code:Any city or county which requires a permit to construct,alter, 10.00
rtu,Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC. LIC.NO. ELEC.
Ea G ¢ requires the applicant for such permit to file a signed statement that TOTAL
n w m m he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
HZQ
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 D Business and Professions Code)or that he is exempt therefrom and GTY. PLUMBING PERMIT FEE /� O
the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
nom -
by any applicant for a permit subjects the applicant to a civil penalty gLTER-DRAIN&VENT-WATER (EA.) y00 ae
of not more that five hundred dollars($500).): ,
❑ 1,as owner of the propeny or my employees wan wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work.and the sl ructum is not
intended or offered for sole (Sec. 7044, Business and Professions DRAINS-,FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor'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 re through his own employees.provided however,
such improves
or
rans eimprovment of tended or within
ed one or year
o If.completion the theo owner. GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement is e b within one year of completion, the o r m-
builder will have the burden of proving that he did not build or int- iGAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
prove for purpose of sated. RES. IND CON PB On.,
❑ d as owner of the property,he exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ 0 ❑ ❑ ❑
licensed anions ors to construct the project La 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCE L NO.
and Professions Code:The Contractor's License s thereon,
docs not apply
co an owner of property who builds to improves thereon,ana who LAWN SPRINKLERS-OVER 5(EA.) 1.00
mouton for such projects with a contractors)licensed pursuant to
the Contractor's Licenu Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,ILAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACG DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to self-insure.
or a certificate of Workers Compensation Insurance,or a certified ZONING ENG.SITE NO,
copy lllerL'orlsao o,Ian.C.l.
PoIivy N ompany
U
Z Certified copy is hereby fur h tbccA f A �z/2y 20
t z Z Certified Co is 0et1 with lute-dtY�tt(gTCt dh d7+ISR FIRE SPR INK ENERGYT-24
O cu MISC.- REFER TO ORD. 'Y ❑ N Y NE]
CC y Cli I A'I' P Fm:Nt PTION FROM WORKERS' PERMIT ISSUANCE ,]a.BO fh FLOOD 20NE A.L.U.C.
LU 1 COMPENSATION INSURANCI? PLG.CONTR. LIC.NO. PY NLG
CL O . Y NE]
section need not be completed if the permit is for one TOTAL - W_
:D 2 hundred ]ollars 1$1001 or less.)
0 O I certify that in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
tl F mit is issued,I shall not employ any person in any manner so as to
Ow become subject to the Workers'Compcnsation Laws of California. BUILDING
O_ lyase Applicant ALTER OR ADD TO MECH. 5.00
} to NOTICE TO APPLICANT: If,after making this Certificate of['a.
Z F- neption,you should become subject to the Workers Compensation_ APPLIANCE 5.00 PLAN CHECK
provisions m the Labor
pe Cit shall
you dmustevoted
forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000 C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I 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. MICROFILM
3097,Civ.C.), HEATING UNIT(TO 100,000 B.T.U.) 8.00
.Lender's Name HEATING UNIT(OVER 100,000 B.T.U:)9.50
Lender's Address ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply withall city and county PLUMBING (M
ordinances and state laws relating to building construction, and BOILER-COMP13 H.P,or 100,000 B.T.U) 6.00
hereby authori/c representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
(We ree to save, indemnify and keep haimless the City of MISC.- REFER TO ORD.
Cu �Oldlili s,j gments, COAs and expenses which CONST.TAX
m6y ic a st Said City in consequence of the PERMIT ISSUANCE 10.00
gra"[ MECH.CONT. LIC.NO. MECH.
\ ` �o� TOTAL TOTAL
X Siy I c of Ap beam/Contractor ate
INSPECTOR COPY