09735 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT lDENTIFICATION PERMIT NUMBER
BUILDINGAPPLICATION & PERMIT
0�.�
AO REss
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
35
OWNER'5 PLAN CHECK VALIDATION
Nr
CITY. ELECTRIC PERMIT FEE
vHONE o -I '
COPI&ACTORS y� UTLETS-SWITCHES-RECEP 10.00/1.00
Q�3:r1 s ( L ' ^ LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4
ADDRESS
PEON -Q PANELS 0.00 h
DATE OF APPLICATION
ORCHRECT PANELS (OVER 200 AMP) 20.00 P PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5,00 PER MIT dA1pLIYaT1pN
ZIP EMP. METER OR PO INS. 20.00 rr/'1!{Y
APPLICANTS MOTORS SEE FEE SCH.
RESS
SERVICE CHAPd 20.00 {{ p ��d�rI�
woo LICENSED CONTRACTORS DECLARATION TEMP.POL 30.00 oI VU
¢
in I hereby affirm flint Ian, liccnwd under m,wisionsof ClemICT 9 ISSUANCE DATE
u (commm�cimg with Section 7000)of Division 3 of the Business and a
¢ BLDG. ELECT. P G. MECH. 1
H z Pml'essinns Codc n<y; kin,l'icctuu i. in full fore and effect �d
z License Cla s t�yl„Q-Lic.Number
o H w Dab; -L��`d`T-Contractor
BUILDING ERMIT
¢ ¢ ¢ OWNER-BUILDER DECLARATION
o s u INFOR ATION
w g LL w I hereby afl'irn that I sin exempt frzun the Contractor's License a MISC.- REFER TO ORD
LL_ oa Law for the hellowingreuson.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code.Any city or county which r miresa permit to construct.alter,
re ¢ Q p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
aa
- o u requires the applicant for such permit to file a signed statement that TOTAL ERMIT TO
n w m he is licensed Pursuant to the provisions of the Contractor's License
Fz >
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
¢ 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 1 ST RIS TYPE CONSTR.
dI- °' by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
O I,as owner of Ore property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 ocD.GROUP RES.UNITS
sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions ngjl COND. 5.00 �{Q
Code:The Contractors License Law does not apply to an owner of
property who builds or improves thereon,and who does such work JZ FIXTURES-PER TRAP 5.00 -W 50.FT,FLOOR AREA TOTAL ACREAGE
. himself or through his own employees.provided that such imprme- -
mentsarenotintendedoroffered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00 pO
or improvement is sold within one year of completion, - . -OVER 4 (EA.) 2.00 the owner- GAS EASYSTEM
builder will have the burden of proving that he did not build or im- BUIL TNG E
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND o vB Omer
❑ 1,as owner of the property,am exclusively contracting with ElCl ❑ ❑
licensed contractor, to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSOR PAPCELNO.
and Professions Code:l'he 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 _
contracts forsuch prhjecls with it contractors)licensed pursuant to SEWER-SANITAR V-STORM EA.200ft/10.00
the Contractor LicerV,Law. TRACT NO. PARCEL NO.
❑ 1"m exempt under SCC.-,B&RC for this WATER HEATERJMNE6AIT 6.00 I
reason � t
Owner, Date WATER SYSTEM 5.00 ;oo ACC.DATE ACC.FILE-NO.
WORKERS'COMPENSA'I'1 ON DECLARATON WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate oI consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
ropy thcmof(Sec.3N00,Luh.C.1 r7D/)n i�
copyther. 00, puny�/[(� f
O ❑ Certif red copy is hereby famished. FIRE SPRINK ENERGY T 24
_Z Z ❑ 'cru d cop is fled t I�IIfe 'eiiy inspection division. MISC.- REFER TO ORD.
O Appliculc e fa I�n"^Pq�b 'b� Y ❑ N❑ Y ❑ No
CC va PERMIT ISSUANCE 10.00
� - Chi II'ICATIi OP ILYIiMP'1lON PROM WORKERS' FLOOD ZONE A.LU.C.
L COMPIiNSATION INSURANCES PLG.CONTE. LIC.NO. PLG. Y N❑ V❑ NC]
(This section need not be completed if the permit is for one TOTAL
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
L F mit is issued, I shall not employ any person in any manner so as to
Ow become subject to the Workeri Compensation Laws of California.
a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE TO APPLICANT: If,after making[Ibis Certificate of Ex-
F Z emhption,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such Provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO IOXMC.F.M.) 4.OgL
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM ,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 which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100 B.T.U.) 8.00 h
Lender's Nome HEATING UNIT(OV 100,000 B.T.U.)9.50
Leader's Address ELECTRIC
1 certify that I have read this application and state that the above VENTILATION N (SINGLE) 4.00
. information is correct, I agree to comply with all city and county PLUMBING
ordinances and slate laws relating to building construction, and BOILER- 13 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the 801E -COMP Over 100,000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposca.
(We) agree to save, indenmify and keep harmless the City of - REFER TO ORD.
C. crtino against liabilities, 'udgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
ma in any way accrue : .;est said City in-cons yuence of the
gran �ng of Ih permit. - M H.CONT. LIC.NO. MECH.
�� TOTAL TOTAL
Sim ore of Applicant/ rel forLate'
INSPECTOR COPY
. I