6196APPLICANT TO FILLJ.N INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDING PROJEgT ID NTIFICATION
APPLICATION & PERMIT
BUILDING — ELECTRICAL— PLUMBING — MECHANICAL
PERMIT NUMBER
a�
1v',
OUIL ING
Ap
wry H'
PLAN CHECK VALIDATION
rvA E
CITY. ELECTRIC PERMIT FEE
NE
ORS/-
UTLETS SWITCHES -RECEP 5.00/1.00
IAC.Np V
LIGHTING FIXTURES 5.00/1.00
Ap R
PPLIANCES- RESIDENTIAL 4.00
PANELS 5.40
PHO
DATE OF APPLICATION
OR
OR
ENGINEER
Cie. No.
SIGNS 6.00
PLAN CHECK FEE P.C. N0,
SIGNS TRANS. 3.00'
oDR"S ENc.
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 75.00
ZIP
/1
Au a
AWDUURE5s
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
K
LICENSED CONT RACI'ORS DECLARATION
I hereby afllrlll Ilial I am licensed under prOVIS1Uns m Clla(Iter
(commencing col Section 7000) of Division 3 of 0m Business a
Professions Co am VA license Is in full force O
LicmL' ss VV Lic. Number
ISSUANCE DATE
BLDG. ELECT, PLG. MECH.
❑ ❑ ❑
Uatl' Contract Or
BUILDING PERMIT
OWNIi R-BUILUfiR UECL16 'ION
I hereby affirm that I Am exempt from the CouRacmr's License
Law for lhefollowing reason. (Sec. 7031.5. Businessand Professions
Code: Nry city m county which requites a permit to consuanc . hel,also
prior to its issuance. also
improve, he applicant
or for repair any ind(to File
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
INFORMATION
MISC. — REFER TO ORD
-
VALUATION
$/FT.
PERMIT ISSUANCE 6.00
ELEC. CONTR. LIC, NO.
ELEC.
TOTAL
PERMIT TO
QTY. PLUMBING PERMIT FEE
Law (Chapter 9 (coin me rising with Section 7000) of Division 3 of the
Business and Prolcssiohs Code) or that he is exempt therefrom and
Mme!
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of$eclion 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not marc than five hundred dollars (8500)):
ALTER -DRAIN & VENT -WATER (EA.) 4,00
❑ I, as owner of The Property, or my employees with wages as
their sole compensalmn, will do thm e work, and the stractuis nal
BACK FLOW PROTECT. DEVICE 2.00
OCC. caouP
BEs. UNITS
_
DRAINS -FLOOR, ROOF, AREA,COND. 4.00
intended or Liberec] for sale (Sae. 7044, Business and Professions
Code: 'I'lie Contractor's License Law docs not apply to an owncr of
FIXTURES - PER TRAP 4.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
\
property who builds or improves thereon, and who does suds work
himself or through his own employees, Provided that such improve-
menu are not intended oroffeicd formic. If, however, the building
GAS - EA. SYSTEM -1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion, the owner.
builder will have the burden of proving that he did not build or int-
Prove for purpose of'salc).
❑ I, as owner of the properly, am exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 1.00
BUILDING USE
RES IND CON PB Omer
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
LAWN SPRINKLERS -OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code:'I he Cantractoi s License Law does not apply
to an owncr of property who builds or improves thereon, and who
contracts for such projects with a contractors) licensed pursuant to
the Contractor's License haw.
SEWER -SANITARY -STORM EA. 200ft/6.00
TRACT NO. -
PARCEL NO.
IT l and exempt under Sec.—, B.&P.C. for this
reason
WATER HEATER W/VENT 4.00
Owner Date
WATER SYSTEM 4.00
Acs. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
WORKERS'COMPENSA'I' ION DEC RATION
I hereby ulfinn that I have a certIGCateofco nt toa•If- sure.
or a cerilicate f Workers' Compensation Insur nee, r a c reified
copy the, Lah CA
ZONING
,
ENG. SITE NO.
Pidicy N, nnrpvny
rlflwd copy is hereby lyrMycd.
FIRESPRINK
ENERGY T-24
A icf�ililiud' is filer I me inepeolion divi.a"
v ❑ N❑
v ❑ N❑
MISC. - REFER TO ORD.
' 'If I'E OP ;XFMP"I[ON PROM WORKERS'
PERMIT ISSUANCE 6.00
FI.00DZONE
AL.uc.
PLG. CONTR. LIC. NO.
PLG.
TOTAL
COMPENSA"PION INSURANCE
(Ibis clion recd not he completed if the permit is for one
Y ❑ N ❑
Y ❑ N❑
hundred dollars 151001 ar Icss)
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so as to
OTV MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to tire Workers' Compensation Laws of California.
Uatc APpin+lllALTER
OR ADD TO MECH. 4.00
NODCF TO APPLICANT': 11, after making this Certificate of 17,,--
nnption, you should become subject to the Workers' Compensation
APPLIANCE 4.00
. PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
-FEE
AIR HANDLING UNIT (TO 10=12,F.NL) 3.00
IR HANDLING UNIT (OVER 10MIC.F.M.) 5.00
SEISMIC FEE
CONSTRUCT ION LENDING AGENCY
I hereby affirm !LATI there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) ' 2 00
the performance /c) t , work for which this permit is issued (Sec.
30nder's .e..).
L �D�%�
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UNIT (OVER 100,000 B.T.U.)7.
ELECTRIC.
A � __
Lenders NamAddy
hcmlor's Address
I certify l5ml l have read this application and state that the above
into nn ation is cornet. 1 ugnu to comply with all city and county
onllnmices and stale laws relating to building construction, and
VENTILATION FAN (SINGLE) .3.00
PLUMBING
BOILER-COMP(3 H. P. Or 100,000 B.T.U.Y'QO
BOILER -COMP love, 100,00OBTU)SEE FEESCH.
MECHANICAL
qct
mss'
hereby aulhmirc representatives of this city to enter upon the
above-menlioncd PrupcUy for inspection purposes.
MISC. - REFER TO ORD.
CONST. TAX
-
(We) agree to save, irW ramify mol keep harmless the City at
ertino a- insl Iiubiltrics5judgments, costs and expenses which
'11 nee wind said Cit in caress
vy n g' Y 4ucncc of thu
n of is pe til �
�d
Latune
PERMIT ISSUANCE - :3.00
ri.
ME H. CONT. UC. NO. MECH.
TDT
TOTAL
d AI Iicant/C,m Rrctur ate
INSPECTOR COPY `-y_