4333 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
BU I LD ING PROJECT I DENTIF I CATION I
PERMIT NUMBER
BUILDING APPLICATION & PERMIT
AO4333
ZgA)i _ 14�/� / /? BUILDING -ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S ! (C�- ` PLAN CHECK VALIDATION -
NAM QTY/�C ��� QTY. ELECTRIC PERMIT FEE
o/ I
' / ' -) C�l� PHONE
GoNTRACTO4RI OUTLETS-SWITCHES-RECEP 5.00/1.00
TIME` M 1�rN0, LIGHTING FIXTURES 5.00/1.00
CONTRACTORS
TORS Pi APPLIANCES-RESIDENTIAL 4.00
Pon 6e 100,3 (`Rr1PnE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.60 PLAN CHECK FEE P.C.N0,
OR
ENGINEER
uc.NO SIGNS TRANS. 3.00 PAN
moo Ess viva SPECIAL CIRCUIT 5.00 PERM( v oN
ZIP TEMP.METER OR POLE INS. 15.00 Al1G
.APPLICANTS MOTORS SEE FEE SCH. V
ADDRESS
SERVICE CHANGE 10.00
n ¢ z City
Ot CU -
r o o LICENSED CONTRACTORS DECLARATION - 3 nertino
' .0 l hereby atTno that l am,licjucd under pnevisionsof Chapo,I) tp ISSUANCE GATE
'NQa (commencing wlth$ecY d7008Pof-0irizion 3utthe Business BLDG.' ELECT. PLG. MECH:
r m i Professions COAfrap m license Is in full forcL h�ef�et ❑ ❑ ❑ ❑-
z o - Lately Clavi Ll..... Con gumbo
o z r Date d' Contractor
a Y s BUILDING PERMIT
IF IF w ¢ OWNER-BUILDER DECLARATION
F
g 1 hereby nHinn that I ant exempt Done tire 6 mtraU -License
MISC.- REF ER TO ORD INFORMATION
Es ,C, VALUATION 5/FT.
H LL o G Law far[lie following reason (Se,7031 5 Bus. dPrlf ss,ons PERMIT ISSUANCE 6.00 'gyp
LI Code:Any city my h,ch r qui, �t rnl t t onstrlmLaller. /D
¢ ¢ ¢ 0 improve,demolish,or Repair any structure,prior to is Issuance,also ELEC.CONTR. LIC.NO. ELEC.
- O IF requires the applicant for such permit m file a signed slmement that TOTAL PERMIT TO
wes" he is licensed pursuant to the provisions or the Contractor's License
Fzi
Law(Chapter 9(conimencing with Section 7000)ofDivision 3 ofthe
¢ Business and Professions Code)or Mat he is exempt therefrom and QTY. PLUMBING PERMIT FEE ` V
¢ F the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
03 $
by any applicHedher.permit sDbj,ct,thcapplicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00 /
of nut more than five hundred dollars(55001.1:
❑ L as owner of the propert,or my cruploy,es with wages IIs BACK FLOW PROTECT. DEVICE 2.00 occ GR HES.UNITS
their Sole compensation,will do the work,and the slmdure is not �P
intended me offered for sale(Sce, 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law docs Inst apply to nn ower,of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO,FT.FLOOR AREA TOTAL ACREAGE
himselforoti meters own employees.providedthatsuch improve. ••
mmselfo through
his or ffemd employee yle.ICed that r.such
ebuddiny GAS-EA.SYSTEM-1INC.4OUTLETS 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 ino-
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 RES IND CON - PB oma,
❑ 1,as owner ul the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the protect(Sec. 7044,Business LAWN SPRINKLERS-1 INC5 V.B. 5.00 ASSESSORS PAHCEL NO.
and Professions Code I lie Contractor's License I.uw does not apply
to an owner of property who builds or improves thereon,and who LAWN SPR IN K LERS-OV ER 5(EA.) 1.00'
contracts for such projects write a contrvaorts)licensed pursuant to
the Contractor',Lie...c Law. SEWER-SANITARY-STORM EA'.200'8/8:00 II1,tTIACT-BIG,. -•;.PARCEL NO.
Cl I am exempt under Ser.-.BAPHC.liter this WATER HEATER W/VENT4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE Arc FILE NO.
WORKIiRS'CObIP1;NSATHON DECLARATION WATER TREATING EQUIP. 4.00
1 hereby itfanh that I have a ccr 1111II.utennscnt to ,HGlnsv re. IZONING b ,-. or a certificate of Workers Conhpensat on Insurance,or a certilicd ENG.SITE NO.
copythee 8 s.l.ajh.CJ"�rjj� LL''L
In y
O ❑ Certified'copy is hereby fyis ished. FIRE SPR INK , ENERGY T24
z Z C,iii SE II�y p(,Icd vd�I}�t I(�Isp t u�,T;l;vlslon.
O Applicant 1�/`, .�E-E' /yL'`L-IGI[.1� I\L MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
jr Hy CIiRTIPICPERMIT ISSUANCE 6.00 FLOOD ZONE aLc
u .
. > CON ION OP EXEMPTION I'ROM1I WORKERS'
W _ CON INSURANCE PLG.CONTR. LIC.NO, PLG.
CL 0 ('This section need not be completed if the permit is fnr one TOTAL - YE] N❑ Y E] NE]
hundred dollars(S 100)or hr,,)
U O I certify that in the performance o!the work In,which this par- QTY. MECHANICAL PERMIT .f.'` FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any nhanner so as to
OU becol g Subject to the\Yorkers'Compensation Laws of Cali(urnid.
C. Date Applicnnl ALTER OR ADD TO MECH. 4.00 BUILDING •��. /
} to NOTICE TO APPLICANT: If,after making this Certificate of nix-
(_ Z eruption,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 pCRIDU shall be devoted revoked. AIR HANDLING UNIT(TO IOSMC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10)"C.EM.) 5.00 SEISMIC FEE
I hereby AT...I that there el a construnion lending agency Lu EXHAUST HOOD (WITH DUCT) 2.00
the performance .1 Elie work for which this per nhit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name `
Lender's Address HEAT(NG UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
Ileintonnation is correct I agree to comply with all city and County PLUMBING
hrdinunccs and stat, laws relating is, building construction, ami BOILER-COMP(3H.P.or 100,000 B.T.U.) 4.00
h...by aullenuirc repo,...tatvcs of Ihls City to circ, upon the BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL
above-nientioned Properly for inspectno Purposes.
is C) agree to Savc, indemnify and keep harmless the City of MISC.- REFER TO ORD. - K
Cur itom against liabilities,judgments, toric and expense,which CONST.TAX g J
man any uay acerin'Lgainst said City in consequence of the PERMIT ISSUANCE 3.00
gm Ong oft 'e Rcrmit. MECH.CONT. LIG NO. MECH.
�- TOTAL TOTAL
Signat eofApplicant(Contractor Date 7.
INSPECTOR COPY
i