09678 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT � ^n�
ADDRESS
� BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 09678
r
OWNER' PLAN CHECK VALIDATION
/ NAME p - ^�1 OTV. ELECTRIC PERMIT FEE
S,rl C PHONE r30
name ncroRs UTLETS-SWITCHES-RECEP 10.00/1.00
LIG.No. LIGHTING FIXTURES 10.00/1.00
ADDRESS Tov's APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
OR
ARCHITECT PANELS (OVER 200 AMPI 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
noo Ess ENG. PERMIT CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP. METER OR POLE INS. 20.00
APPLICANT'5 MOTORS SEE FEE SCH.
ADDRESS /
SERVICE CHANGE 20.00
o 9 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
Q u w 1 hereby affmn that I am licensed under,provisions of Chapter 9 ISSUANCE DATE
H G w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H as zProfusions Code,an,]my license is in(all force and effect
o 0 w o License Class Lie.Number i
Date Contractor
a Y s 1 BUILDING PERMIT
a OWNER-BUILDER DECLARATION,
0 0 d U INFORMATION
wg LL e. 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
IL 0 j Law for the following reason.(Sec.7031.5,Business and Professions VALUanON $/FT.
- PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit m c7netr ct,alter,
2 ¢ ¢ improve,demolish,or repair my structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC.
ca
0 ¢ requires the applicant for such permit to file a signed.statement that TOTAL
a w m w he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
H z A Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 0 Business and Professions Code)or that he is exempt therefrom and CITY, PLUMBING PERMIT FEE
is the basisforthealleged exemption.Any violation of Section703LS I STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATEfl (EA.) 5.00
of not more than five hundred dollars($500),)'.
❑ 1,us 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 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
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 $O.FT.FLOOR AREA TOTAL ACREAGE
•
armors
are
not hrough
ownemployees,for sale.
If,ed ever,the
Improve- GAS-EA.SYSTEM-l 6.00
mems are not intended or offered for sale.IL however,the building
Or improvement is sold within one year ofdion,tine owner- GAS EASYSTEM-OVER 4 (EA) 200
builder will Ithe burden of proving tile,he did he did not build nr - . . .
im- ; BUILDING USE
prove for purpos,00 e of sole.). INDUSTRIAL WASTE INTER. - 30.00 RES IND CON PB Omer
❑ as owner of the property,um exclusively contracting with
licensed
ttmtrsmoto construct the project(Sec. 7044,Rosiness LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL N0.
Code
and Professions grope The who
buildsContractor's improv Law does not apply
to contracts
owner of property who builds or tropanes licensed
and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
the Cont for such projects with a contractor(s)li,enud pursuant ro SEWER-SANITARY-STORM EA.200ft/10.00
the GOnlmC104s License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,H 1P.0 for this WATER HEATER W/VENT 6.00
reason s
Ownern i '^r-v-°.� WATER SYSTEM 5.00
ACC.GATE ACC.FILE NO.
WORKERS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate ofconsent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
U Cl Certified copy is hereby fuoushed.
Z Z ❑ Certified copy is Filed with the city inspection division. 'FIRE SPR INK ENERGY TSA
O Applicant MISC.- REFERTOORD. YE] N� Y [D NE]
cc W CE RTI ITCA 'E OF EXEMP PION FROM WORKERS' PERMIT ISSUANCE 10.00/6 FLOOD ZONE A.L.U.C.
LU � COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. (f-U V� N� V� N�
? 0- O (This section need not be completed if the permit is for one TOTAL
Z h unit red dol l am IS 100)of less.)
U O 1 certify that in the performance of tiro work for which this per OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued, I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of Culifemiia.
a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE 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
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 10=11F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 6.00 SEISMIC FEE
I hereby affirm that Lbere is a comst,netion lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the pcffonnonce 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 HEATI NG UNIT 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and stale Hot the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and stale laws relating to building construction, and
et U
hereby amhuriw represenmtives 71' Ibis city t7 enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH.
above mentioned property for inspection purposes. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
lie
Cupert' o against lu judgments, costs and expenses which CONST.TAX
may o try way a c u must said City in consequence of the PERMIT ISSUANCE 10.00
gr ting it P 1L MECH.CONT. - LIG NO. MECH.
_ - TOTAL TOTAL
' veto CApplic. /Contmct7r Data '
INSPECTOR COPY