6267 (3) APPLICANT TO FILL IN INFORW&TION WITHIN RED LINES - USE B POINT PEN ONLY
BUILDING PROJECT I DENTI FICATI .. PERMIT NUMBER
aDrLDINGt APPLICATION & PERMIT
AotiEss UILDING - ELECTRICAL-PLUMBING-MECHANICAL 6267
OANER' J "J PLAN CHECK VALIDATION
T' rvaME PTY. ELECTRIC PERMIT FEE
'� �Jr I PHONE Jam! j�j
CONTRACTOR'S UV -
NAME UTLETS-SWITCHES-RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
CONTRACTORS
/ ADUREss PPUANCES-RESIDENTIAL 4.00
PHOxE PANELS 5.00 DATE OF APPLICATION
ARCRt ECi SIGNS 6_0Q PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH (
. \
SERVICE CHANGE 10.00
o Ix //,,
.Foo LICENSED CON'I'RAMORS DECLARATION. V//114 Ss'�
p.. 4 u u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
m Z w (curia with Section 7000)of Division 3 of the Business pod BLDG. ELECT. PLG. MECH.
r m z I'rol'vssions Co al y license is in full for,, nil eff et 1 /
oz set D Licunsc Class Lic.Nwnber VT E]
w r an 'Dale Contractor
IL ¢ Y a OWNER-BUILDER DECLARATION BUILDING PERMIT
_ ¢ w INFORMATION
4 o a tr MISC.- REFER TO ORD
3 r 1 hereby affirm that 1 am exempt from the Contractor's License
to is Law for the following reason. 7031.5.Businessand Professions PERMIT ISSUANCE 6.00 VALUATION SIFT.
Fmv� Code:Any city or county which requiresapermit to construct,alter. ELEC.GONTR, LIC.NO. /O )•
o improve,demolish,or repair any structure,prior to its issuance,also ELEG / 1
D M requires the applicant(or such permit to file a signed statement that TOTAL PERMIT TO
K
mhe is licensed pursuant In the provisions of the Contractor's License
Hzi
Law(Chapter 9Commencingwith Section 70000o'Division 3 ofthe ,9v(fi 7e�
a Business and Professions Code)or that lie is exempt therefrom and CITY. PLUMBING PERMIT FEE
ago the basis for the alleged exemption.Any violation ofSection 7031.5 STORIES TYPE CONSTR.
Lo � _ by any applicant for a permit subjects the applicant to a civil penalty - ALTER-DRAIN -WATER (EA.) 4.00
_ of not more than five hundred dollars($500).):'
❑ I,as owner of(he properly,or my employees with wages as BACK F LOW PROTECT. DEVICE tr2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the sucture is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CONE). 4.00
it Code:'I'tic 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 4.00 SO.FT.FLOOR AREA TOTALACREAGE
` himself or through his own employees,provided that such improve-
nutldsala not intended orol'fiered for sale.if,however,the hutting GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvemmut is sold within ono year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or Ira- RES IND CON PB Omer
prove lie purpose of salc.L INDUSTRIAL WASTE INTER. 20.00
❑ ❑ ❑ ❑ ❑ ❑
d,as owner of the property.am exclusively contracting with
licensed anmrnefors m c nstruet me project(Seo. 7044,Business LAWN SPRINKLERS- I INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Prufesions Code:flue Contractors License Law does not apply -
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
conracle for such projects with it contractors)licensed pursuant to
the Cortract,Wv License Law, SEWER-SANITARY-STORM EA.200ft/8.00 TRACTNO. PARCEL NO.
❑ I:un exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
wORKGRS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 4.00
I hemby affirm that 1 have a crH cote of cot to self-insure, ZONING ENG.SITE NO.
ora certificate of Workers'Compe fol 0*rdI!°,or a certified
"1C C py thereof(Sec.3800,Lab C.).
Policy No. Con ny
O ❑ C4tlih deo yixh by(amishyyd. FIRE SPRINK ENERGY T 24 "
z Z ❑ CenilieJ opy i filed with the iy inspection division. MISC- REFER TO ORD.
O> Applicant Y❑ N❑ Y N❑
OIi RTIiCA"1'E •p kXIiMPI'IO FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.c.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL ('f his section need nut be completed if the permit is fur ane TOTAL v❑ N❑ Y❑ N❑
Z) Z hundred dollars IS 100)m less.)
U O 1 certify that in the performance of the work for which(his per CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued.I shall riot employ any pave in any mannerso as to
U hecoma subject to Ilse Workera Cumperuution Laws of California.
O w BUILDING / 3 au
D. Date.Applicant ALTER OR ADD TO MECH. 4.00
} m NO'I'ICE'10 APPLICANT': 11',alter making this Certificate of Lx-
F, Z emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
Provisions of Ilio Labor Code, you must forthwith comply with FEE
" U melt provisions or lits permit xIodl be deemed revoked. AIR HANDLING UNIT(TO 1Q000GF.M.) 3.00
CONSI'RUC'I']ON LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 /SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
' the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
1"tiny that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction,and BOILER-OONIP(3 H.P.or 100,000 B.T.U.) 4.00
hereby au(horiee representatives of this city to enter upon the BOILER-COMP IOver IGGODO8TU1 SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
Lma
We) agr to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
ertino gains "(ie nts, costs and expenses which CONST.TAX
in way ace ag s( sat City in consequence of the PERMIT ISSUANCE 3.00
n - 1 ME .CONT. LIC.NO. MECH.
G� TOTAL TOTAL '�Q
/ alum of Appli nl/Contractor Dale
3/ S
INSPECTOR COPY