C09733 1
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BEI LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
80ILDING-aiqy✓'� APPLICATION & PERMIT
ADDRESS PDT ,1 "✓
,`1 ` BUILDING - ELECTRICAL-PLUMBING-MECHFE
. Q9733
OWNED'5 PLAN CH KVALIDATION
�JC NAME OTY. ELECTRIC PERMIT
ONE
CONTRACTOR'S
NAE OUTLETS-SWITCHES-RECEP 10.00/1.00
uc.No. LIGHTING FIXTURES 10.00/1.00.
CONTRACTOR S APPLIANCES-RESIDENTIAL 4.00
ADDRESS
p- PHONE - �/ PANELS 10.00
DATE OF APPLICATION
AnxiolICI PLAN CHECK FEE P.C.NO.
OR - PANELS (OVER 200 AMP) 20.00
ENGINEER
uc.NO r f SIGNS TRANS. 3.00
AARCH OR DDRESS ENG. SPECIAL CIRCUIT 5.OQ PERMIT VALIDATION
ZIP EMP. METER OR POLE INS. 20.00
ADDRESS rS
AMOTORS SEE FEE SCH. .
ADDRESS
SERVICE CHANGE 20.00
,00 LICENSE D CONT RACTORS DECLARATION TEMP.POLE 30.00
G u V I hereby affirm Unit 1 on licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
rn a vi BLD ELECT. PLG. MECH.
r i z Professions Code,and my license is in full for e t nd e f c1. E]
P.:
- LicenContractor
se Class l- mer
Nubr`c-5
9 m r w Dale - � "" �
BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILDER DECLARATION -
R o s oINFORMATION
X g LL I hereby affirm that 1 ran exempt from the COn[mct Dr'S License MISC.- REFER TO ORD VALUATION
FLL0J Law for the litllowivg reason.(Sec.7031.5,Business Professions PERMIT ISSUANCE 10.00 $/FT.
Code:Any city or county which requires a permit to construct,alter,
2 in¢¢p improve,demolish,or repair any structure,prior to its issuance,also ELEC.OONTR.n LIC.NO. ELEC.
O ¢ requires the applicant for such permit to tile u signed statement that TOTAL
X
A ¢es he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
R z
Law(Chapter 9(Commencing with Section 7000)o'Division 3 ofthe
E D Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
; �2 by any ,hemot for aPermit ollt is the applicant m a Uvd penalty ALTER-DRAIN& VENT-WATER IEA.) 5.00
of not more than five hundred dollars(S 500).1'.
❑ L as owner of the property,or my employees with wagesas BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
thea .to
thaubmsation,,ill do the work,and the structure is not
intended or olfefed 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
property who,builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTALACREAGE
himself re through his own employees,sale.Provided thus such ire Prove- -
Intlarenotintcndedoroffereoyees, rovided that such
emprovg GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 ,
builder will have Ute burden of proving that lie did not build or ire- BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RE IND CON PS Omer
CI 1,as owner of the property,ant exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASBEgsoas PARCEL NO.
and Professions Code.The Contractor's License Law does not apply
to an owner of property who builds or improves thercon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractons)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00
the Contract.,',License Law. TRACT NO. PARCEL NO.
❑ lura exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO-
f WORK ERS'COMPENSATION DECLARA'NON WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
AT a coUiticatc of Workers'Compensation Insurance,o a ienifieA
copy thercof(Sec.380 Lab.CJ. _
Policy kD4(? I�a Pant
Q ❑ Cer lGed pY hslcreby furnislieZl. FIRE SPRINK ENERGYT24
Z Z ❑ Cert copy lit yYwith the city inspection division. MISC.- REFER TO ORD.
Ol' Applicant V ❑ N❑ r Y ❑ N❑ -
DC N CERTI FICA'r P ION PROM WORKERS, PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.0 C.
W � COMPFNSA'TIO INSURANCE, PLG.CONTR. LIC.NO, PLG.
CL 0 This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y [:] NE)
hundred dollars(8100)or IessJ
U O 1 certify that in the performance of the work for which this per, CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL f Init is issued,I shall not employ any person in any manner so as to
Wbecome subject to the Workers'Compensation Laws of California.
Q. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_
m NOTICE TO APPLICANT: If,after making this Certificate of Ex-
L.. Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
pvisions of the Labor Code, you must is thwith comply with
U sucroh provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 FEE t
CONS'rRUCTION-LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD`(WITH DUCT) 5.00
the performance of the work for worn this permit is issued(Sec. MICROFILM
3097,Civ.C.). H EATING UN IT ITO 100,000 B.T.U.) 8.00
Lenders Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lenders Address ELECTRIC
I certify that l have read this application and State that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING ,
ordinances and state laws relating to building construction, and BOILER-COW(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
abovewcntumed property for inspection purposes. BOILER-COMP (Over t00,000BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Caperfit. against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue-again aid.City in consequence of tilt
granting II permi. CH.CONT. LIC.NO. MECH.
TOTAL TOTAL
�l Signa ore f KPplicant/ ntractor z Date
IF INSPECTOR COPY
a