8232a
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING -ELECTRICAL -PLUMBING -MECHANICAL
PERM IT NUMBER
I
` 18232
BUILDING
ADDRESS
UwNER
NAME
11 1&
QTY. ELECTRIC PERMIT FEE
\PLAN CHECK VALIDATION
PHONE
n°M°TO
EOUTLETS-SWITCHES-RECEP
10.00/1.00
t
p LIE. NO.
LIGHTING FIXTURES 10.00/1.00
ro T A oRs ^ /���'
ADDRESS Ci/� �o1f cooO l
APPLIANCES -RESIDENTIAL 4.00
PANELS 10.00
rV WV PROry
DATE OF APPLICATION
On
ENGINEER
uc. rvo.
PANELS(OVER 200 AMP) 20,00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDRESS eec.
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
nuoRess s
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
Qe_
(
{OI//i'S
LICIiNSI;D CONTRACTORS DECLARATION
TEMP. POLE 30.00
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Seel ion 7000) of Di ""on 3 of thLEsiness and
Professions Code, and my license is in fu to e
License Class G Ill Q` _ Lic. Num
Date
ISSUANCE DATE
BLDG.
El
ELECT.
El
PLG. MECH.
❑
_Contracts
OWN :R- UILUER DEC RA ION
1 hereby affirm that I am exempt from the COnsT0C10r5 soars
Law Code: Any city county whichec.7W1.5. a permit to con Pro salons
Code: Any city or county which requires apermir to construe alter,
improve, demolish, or repair any structure, prior to its i1 uan e, also
requires the applicant for such permit to file a signed star Ent that
he is licensed pursuant to the provisions of the Contractor's License
BUILDING INFORMATION
INFORMATION
MISE.- REFER TO ORD
VALUATION
,a•
SIFT.
PERMIT ISSUANCE 10.00
ELEC. CONTR. LIC. NO.
ELEC,
TOTAL
P R I TO
QTY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
.i /
the basis for the alleged exemption. Any violation of Section 7031.5
1 STOPI TYIPE TR.
by any applicant for a permit subjects rhe applicant to a civilpenalty
Inure than five hundred dollars (S500).):
of nor m
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work
himself or through his' own employees, provided that such improve-
Rents are not intended or offered for sale. If, however, the building
/
. .
ALTER-DRAIN-WATER'IEA) 500
BACKFLOW PROTECT. DEVICE 4.00
DCC. GROUP
RES. : UNITS
4or,
_
DRAINS -FLOOR, ROOF, AR EA, COND. 5.00
F IXTUR ES - PER TRAP 5.00
6D, FT, FLOOR AREA
,
TOTAL ACREAGE
GAS - EA. SYSTEM -11NC. 4 OUTLETS 6.00
or inrpmvenenr is sold within one year of completion, the owner-
e burden of proving that he did not build or im.
builder will have tire
prove for perpcon otsale.).
❑ 1, as owner of the property, am exclusively contracting with
- . -..
GAS EASYSTEM OVER 4 (EA.) 200 -
BUILDING USE
RES IND PB -Omer
❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project (Sec. 7044, Business
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 - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS A CEL NO.
contracts for such projects with a contractors) licensed pursuant to
the Contractors License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
0 1 xn. exempt under See.-, B.&P.C. for this
WATER HEATER W/VENT 6.00
reason
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACG FILE NO.
WATER TREATING EQUIP. 5.00
WORK HRS'COMPENSATI�` DECLARATION
1 hereby affirm tllat I M1aVe 8 CefNr ate of consent to self -insure.
of a cerlificate of Workc,, Compensatl•m InJsuran1�ce, orraa ccnificd
here r"Sec. 3 00.1
copy ",
policy N(. '1}t�,•
❑ Ce111 (icd ylti Pfrc ami.
A I�`C I ed "I is f •d rIT tI, L 'ns le i division.
iB 'kry
ZONING
ENG. SITE NO.
FIRE SPRINK
Y N
❑ ❑
ENERGY T4A
y N
❑ ❑
MISE.- REFER TO ORD.
Clift' IMCAA ;01: EXP.M ('101.I'Ro WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U.C.
PLG. CONTR. LIC. N0.
PLG.
TOTAL
('OM PENSAIIO INSURAN ti
('f his section need not be completed if the permit is for one
V ( N
❑ ❑
❑' ❑
Y N
It dred dollar-, (S 100) or Icn.)
I certify illat in OIe performance of the weir for which this per-
mit is issued, I shall not employ any pe any manner so as to
beconm subject to rhe Workers'Compensation Laws of California.
Date Applicant
NOfICIi 'f0 APPLICANT: If, alter making this Certificate of Ex-
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
FEE CHECK
emption, you should become subject to the Workers'Compensation
provisions of rhe Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed Tevoked.
AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00
SEISMICFEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm ilial 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.
3097, Cw.C.).
MICROFILM
'
t
HEATING UNIT (TO 100,000 B.T.U.) 8.00
H EATING U N IT (OVER 100,000 B.T.U.) 9.50
ELECTRIC
Lender Name -
Lender's Address
I certify that I have Tcadxrhis application and state that the above
ploonation is correct. I agree to comply with all city and county
pprdinances and stare laws ((elating to building construction, and
VENTILATION FAN (SINGLE) 4.00
PLUMBING
BOILER-COMP(3 H.P. or 100,000B.T.U.) 6.00
BOILER -COMP (Over 100.000 BTU) SEE FEE SCH. '
MECHANICAL
h vchy authoriac representd ives of this city to enter upon the
Iibove-mentioned prop ty to Inspection purposes.
MISC. - REFER TO ORD.
agree to save, i' defy and keep harmless the City of
t�(We)
pem J ayuimit Iiabill it. , /u 'merits, costs and expenses which
y y way occur a oust as id City in consequence of the
CONST. TAX
PERMIT ISSUANCE 10.00
gr OR a his Pero it. f
MECH. CONT. LIC. N0.
TOTAL
TOTAL
2�
SigIr plic' t/Collmct., nut,
��� INSPECTOR COPY