9446 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT 94 46
AO
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
O R 1nA• PLAN CHECK VALIDATION
" Y•_ - TV. ELECTRIC PERMIT FEE
• ONE
om
NERncroR UTLETS-SWITCHES-RECEP 10.00/1.00 --�
LIC.NO. LIGHTING FIXTURES 10.00/1.00
ADDRESS TORS PPLIANCES-RESIDENTIAL 4.00
CONTRC
PHONE PANELS 10.00 DATE OF APPLICATION
onARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
\.
ENGINEER
LIG.No, SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 20.00
APPLICANT Ss MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 �\\
wo O LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00
G .U I hereby al'linn that I am licensed under provisions of Chapter 9 ISSUANCE DATE
I a H (commencing with Section 7000)01Division 3 of the Business and BLDG. ELECT. PLG. MECH!
H o z Professions Code,and my license is in full force and effect ❑ El 11 EY
O i m W License Class Lic.Number
H m H J Date Contractor
a m BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION
A o a u INFORMATION
w 3 LL I- 1 hcrcby.ulfinn that I am exempt from the Contractor's License MISC.- REFER TO ORD
u o v, Law for tiro following reason.(Sec.7031.5,Busioesand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
� - Code:Any city or county which requiresapermit toconstrucl,alto', U •7�
QQ ¢ pimprove, or repair any structure,prior to its Issuance,also ELEC.CONTE. LIC.NO. ELEC so, wJ
¢ requires the applicant for such permit to file a signed statement that TOTAL C)
a w m�` he is licensed pursuant to the provisions of the Contractor's License 1"<y
+ PERMIT TO
HZQ
Law(Chapter 9(commencing with Section 7009)ofDivision 3 ofthe Sx T
E D easiness and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE /
EE r e the basis far the alleged exemption.Any violation oI'Section 7031.5 STORIES TYPE CONSTR.
In by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
.fuel more than fivehundred dollars($500r)
❑ I,as owner of the property,or my employees with waSes as BACK FLOW PROTECT. DEVICE 4:00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and tire structure Is not
intended or offered for sale(Sec. 7044, Business and Professions
Code: ROOF,AREA,COND. 5.00
Code:I tic Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO.FT FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
meats are not intended or offered for Sale If,however,the building GAS-EA.SYSTEM-I1NC.40UTLETS 6.00
or improvement is sold within one yen,of complown,tire owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden ofproviag that[,a did not build or ins- mitik, BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ I,as owner of the property,am exclusively contracting with E] El ❑ 0 El
licensed contractors to construct the project(Sec. 7044.Business LAWN SPRINKLERS- 1 INC'5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs not apply /
to an owner of property who builds or improves thereon.and who v� LAWN SPRINKLERS-OVER 5'(EA.) 1.00 1,.
contracts for such projects with a contractoos)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00
the CONI ctor'.s License Law. / �_.TRACT•NO... PARCEL-NO.
❑ I asenpt under Se . ,B.&P.Cfothis WATER HEATER W/VENT 6.00 ( v
reason
( Owner Dale WATER SYSTEM 5.001 ACCOATE ACC.FILE NO,
W'ORKERS'CONPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.),
Policy No. Company
❑ Cetlilied copy'is hereby l'umislud' FIRE SPRINK ENERGY T 2
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y El N El Y [D N�
~ w PERMIT ISSUANCE 10.00
C - Cf$R'1'IPICAMPENSAIION INSUROb1WORKGRS' FLOOD ZONE A.L.U.C.
W > COMPIiNSATION INSURANCE PLG.CONTE. LIC,NO.
CL O (This section need not be completed if tire cunit is for one TOTAL Y� N Y N
Z) Z hundred d011ars(SID0IOrlc4s.)
U O 1 certify that in the performance of the work for which this per DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LF- mil is issued,I shall not employ any person in any manner so as to
U become suhject to the Workeri Compensation Laws of California.
O a
Date-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING �Q
} W NOTIC17 '10 APPLICANT': If,after staking this Certificate of E.-
2 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 l0
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.NL) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE S�
I hereby affirm that there is a construction lending agencv for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097.Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00 q
Lender's Name HEATING UNIT 100,000 B.T.U.)9.50 oCU CJI
Lender's Address ELECTRIC I C
1 certify that I have read this application and sate that the above VENTILATION FAN (SINGLE) 4.00
• information Is correct.1 agree to comply with all city and county BOILER-OOMP(3 H.P.or 100,000 B.T.U.) 6.00 - PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
pe turn against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
I y in any way accrue against said City in conscqucnce of the
r tingof this P all MECH.CONT. ` LID.NO. MECH.
I INA N9� - TOTAL TOTAL7
,phi , o tr or a ,f r
INSPECTOR COPY