7265 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
mAPPLICATION & PERMIT
ADNEs)-
sINc
2C(e1cn BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 7265
k
NAME $ PLAN CHECK VALIDATION
NAME Lrotyto PTY. ELECTRIC PERMIT FEE lv
P ONE
CONT
NAAMQRncron-s UTLETS-SWITCHES-RECEP - 5.00/1.00
LIC.No. LIGHTING FIXTURES 5.00/1.00
CONTA ACTOR
ADDRESS PPLIANCES-RESIDENTIAL 4.00
ADDHE
PHONE PANELS 5.00 DATE OF APPLICATION
OR
SIGNS 6,00 _7777T
LAN CHECK FEE P.C.NO.
ENGINEER
LIC NO. SIGNS TRANS. 3.00
ADDRESS ENa, ECIAL CIRCUIT 5,00
SPPERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
APPLI MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00 /�(.1
w o o LICENSED CONTRACTORS DECLARATION /1
rt u I hereby affirm Thal I am licensed underprnvisionsof Char err) ISSUANCE DATE zw (commencing with Section 7000)of Division 3 of the Business and
rA A SLOG. ELECT. PLG. MECH.
F w i Professions Code,..it on,license is in full force and effect ❑ ❑ ❑ ❑
z o w_ License Class Lic.Number
o w H Date Contractor
BUILDING PERMIT
ir ¢o at o OWNF-R-BUILDER DECLARATION
INFORMATION
,w I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
F LL m j Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00 VALUATION $/FT.
Code:Any city or county which requires permit loconstrueL alter,
¢ a ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
D , requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
a w m
he is licensed pursuant to the provisions of the Contractor's License
z a Law.(Chapter9(eomcneing with Section 7000)of Division 3 of 0a WO 0") s70 V'�
i D Busim
ness and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
r p the basis for the alleged exemption.Any violation o(Section 7031.5 STORIES TYPE CONSTR.
P.dam by any applicant for a permit subjects the applicant las civil penalty ALTER-DRAIN -WATER (EA.) 4100
of not mom than five hundred dollars($500).): 1
❑ I,as owner of ore property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2100 U
their vote compensation,will do Ore work,and the structure is not occ,caouP RES{,rNITS
intended or offered for sale (Sec. 7144, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractors License Law dues net
apply to an owner of
property who builds Or improves(hereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenodintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improve mot is old within one year of completion,the Owner- GAS-EA.SYSTEM-OVER 4(EA.) 7.00 BUILDING USE
builder will have the burden of proving that he did not build or int- REB IND CON Pe Omer
1,as o
prove r of side.). INDUSTRIAL WASTE INTER. 20.00 11 El El El El
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct IIIc project(Sec 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code;'1'he 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
contrathe Cons for suchicene Lwithacuntructorts)licensml pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
the Contractor's License Lew.
1 ❑ 1 an exon under 5cc. R.&P,C.for this WATER HEATER W/VENT 4.00
reason_
Owner Dale WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPFNSATION DECLARATION WATER TREATING EQUIP. 4.00
1 Imrehy affirm that I have a certificate of consent to sell-insure, ZONING ENG.SITE NQ
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(See.3800,Lab.C.).
Polley No. Company
O O CcrtifCdcopyisheebyfurnished. FIRESPRINK ENERGY T 24
Z 2 ❑ Certified copy is filed with the city inspection division.
F O APplic:ov - MISC.- REFER TO ORD. Y N v ❑ N❑
mPERMIT ISSUANCE 6.00 FLOOD zorvE A.L.u.u.
� CI$RTII4CCOI OF h AX IO TION PROM WORKERS'
IL COMI'IiNSA1'ION INSURANCE. PLG.cOrvTR. LIC.No. PLG. v N v ry Q
CL ('Phis section need not be completed if the permit is fur one TOTAL
2 hundred dollars(5100)or Ica.)
U O I certify that in the pmimmance of the work for which this Per, ATV. MECHANICAL PERMIT FEE FEE SUMMARY
IJ_ F mil is issued,I shall not mnploy any person in Any manner so as to
O L) become object to the Workers'Compensation Laws of California.
O_ Date T(strplicam ALTER OR ADD TO MECH. 4.00 BUILDING S-�)
} W NO'flCl:'10 f PI-ICANT: If,after making this Certificate of nix-
F Z mmption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK K
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 1OXMC.F.M,) 3.00
CONSTRUCTION L17NDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE J�
I hereby affirm that there is a construction lerlding agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work foywhich this permit is•hsucd(Sec. MICROFILM
3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name H EATI N G UN IT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby amhoriee representatives of this city to enter upon the BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL
ahuve-numli un cal property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cup lino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE - 3.00 CONST.TAX
may in any way accrue against said City in consequence of the
got fingo I m1t>` // / MECH.CONT. LIC.NO. MECH.
TOTAL .c'{
TOTAL ,//fj. 7� f•)y/ ,Jly 7.�
Signature or APIT lican /Contractor ate
INSPECTOR COPY