09740 (3) APP,LICANT'TO�FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
B
U
ILDING APPLICATION & PERMIT
ADDRESS q
G. BUILDING-ELECTRICAL-PLUMBING -MECHANICAL 09740
OWNER'S PLAN CHECK VALIDATION
NAE y/5 � QTY. ELECTRIC PERMIT FEE
ONE
CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00
ZviLIc.N LIGHTING FIXTURES 10.00/1.00
0
CONTRACTOR Cl
ADDRESS s' �{/� APPLIANCES-RESIDENTIAL 4.0
PHONE PANELS - 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMPI 20,00 PLAN CHECK FEE D.C.N0.
OR
ENGINEER
�
LIC'NO, SIGNS TRANS. 3.00
ARC H,OR ENG SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00
APPucArvr$ kk-ep MOTORS SEE FEE SCH.
ADDR E55
SERVICE CHANGE 20.00 �-
° 10
da J
o O
LICENSED CON'T'RACTORS 111iCLARATION TEMP.POLE 30.00 1
2 is w I hereby allinn that I am licensed under provisions of Chapter 9 ISSUANCE DATE
v,a 'w (comm enc mg with Section 7000)of Division 3 of the Business and - BLDG. ELECT. PLG. MECH.
F n z 1'rn fessions C Je,and i lw tic se is in full fore d eHe 1. ❑ ❑ ❑
i � osw° Licensc Clas Lic.Numbea4I 1.
H w t: j Dule Contractor
se Y2 BUILDING PERMIT '
wo ° ON'NI>R-BUILDER DECLARATION INFORMATION
n I hereby affirm that I oni exempl from the Contracmr's License MISC.- REFER TO ORD
aLLoJ Law for the following reason. 703 I.S.Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city or County which requires a permit to construct,alteq
improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
°C requires the applicant for such permit to file a signed statement that TOTAL PERMIT T
n w m he is licensed pursuant to the provisions of the Contractor's License , J�
HzaLaw(Chapter 9(commencing with Section 7000)of Division 3 Of the /v/
4 ° Business and Professions Code)or that he is exempt therefrom and QTY, PLUMBING PERMIT FEE
¢.H e the basis for the alleged exemptian.Any violation of Section 7031.5 STORIES TYPE CONSTR,
d3rO by any applicant for a permit subjects Ole applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more 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 coin pensalion,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The 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 5.00 So,FT.FLOOR AREA TOTALACREAGE
himself or through his own employees.provided that such improve.
mcnls are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, - . - . .00 the owner- GAS EASYSTEM OVER 4 (EA) 2
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). 11 INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ 1,as owner ol'the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct lire 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 forsuch projects with a contractor(sl licensed pursuant to SEWER-SANITARY-STORM EA:the Conlraclars License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,B&PIC.far this WATER HEATER W/VENT 6.00
reason
Owner, un. WATER SYSTEM 5.00 ACC.DATE ACC.FILE No.
WO ERS'COMPENSAII LARATI K WATER TREATING EQUIP. 5.00
I hereby affirm that I have a cer 1l to of consent o self-insure, ZONING
or a certif tate of Workers'Com ion umn a cert led ENG.SITE NO.
COPY thcr of(Se"35 ,Lab.
Policy No. in
O ❑ Coniscd co s e
Z Z ❑ Co tificd c with t in n division. FIRE SPRINK ENERGY TQ4
FO Applicant _�_ MISC.- REFER TO ORD. Y[] N� Y ❑ N[:)
cc CERT'I JCA'I'li Oh EXEh1PPION P ORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
LL > COMPENSAT'ION INS PLG.CONTR. LIC.No. k PLG. 'p. ❑ ❑ ❑
(L 0- (This section need not be complete if c Permit is for one TOTAL Y N V N
::I Z hundred dollars(5100)or less.) ilk
U O 'I certifythat in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- not is issued, I shall not employ any person in any manner so as to
O w hecome su_jeel to tie Workers'Compensation Laws of CaliliarniT
n Date Aliplieant "- ALTER OR ADD TO MECH. 5.00 � BUILDING
} to NOTICIi TO APPLICANT: If,after making this Certificate of Ex. _
F Z cmplion,you should become subject to the Workers'Compensation APPLIANCE 5.00PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deem000ed revoked. AIR HANDLING UNIT(TO 10, C.F.M.) 4.00
CONS'fRUCfION LENDING AGENCY AIR HANDLING UNIT(OVER 10.000C.FM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency lin EXHAUST HOOD(WITH DUCT) 5,00
the perl'urmance of tlm work far which this permit is issued(Sec. MICROFILM
3097,Civ.C.), ^/ n -1 HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's �(y�{���f�)� HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's NameAddress'
1 certify t 1261.hav .,-ad•Uis applicatun and state that the above VENTILATION FAN (SINGLE) 4.00
info >aH n Is correct. I agrc to c hp wit if II city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
me,or and state laws rel to buildin construction, and
- mrehy aulhorire represcnta ' es of ih is city to enter upon the BOILER-COMP IOver 100.000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property f inspection par scs.
(WO agree to save, ' emnify and kc harmless the City Of MISC.- REFER TO ORD.
rarlino against Iia ies,judgmenla Hosts .a�hd�expanses which PERMIT ISSUANCE 10.00 CONST,TAX
may way a agam Sidi y in V� cquence of the
gmnlin fd L MECH.CONT. LIC.NO. MECH.
UL
TOTAL TOTAL
i e o A ¢an On, ale Sr,So
\ INSPECTOR COPY