9145 (2) .APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIF PERMIT NUMBER
ICATI_ APPLICATION & PER +,+
BUILDING \9� e!/,t� 5
aoDREss «� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
O E PLAN CHECK VALIDATION
"AME y0 QTY. ELECTRIC PERMIT FEE
IIS' 'J c Q PHONE
CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00
NVE
Lie.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS - APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARRCHITECr PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE PC.N0.
ENGINEER
LIC.NO SIGNS TRANS. 3.00
` \ 'ARCK OR ADDRESS ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS, 20.00 /
APPLICANTS ZIP
SEE FEE SCH. (] "rJ•"
aDDRE55 ,j� 99VV��YYff
�Q) C`a8xu Or- SERVICE CHANGE 20.00
00 LICENSED CONTRACTO SDECLARATION TEMP.POLE 30.00
'.Q
U 1-i I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
m G m (commencing wills Section 700e)i effect,
ft
DC Division 3 of[ Business and BLDG. ELECT. PLG. MECH.
F, m z Professions Code,and my license s in full force and effecF1 ❑ ❑ El
License Class Lic.Nwnher
`o
to Date, Contractor
¢.y f BUILDING PERMIT
¢ a OWN['R-BUILDER DECLARATION
a o a " MISC.- REFER TO ORD INFORMATION
w 3 LL H I hereby aflirn that I am exempt front the Contractor's License VALUATION H,F u o a Law for the following reason.(See 7031.5.Bmeinv,,m d Professions PERMIT ISSUANCE 10.00 $/FT.
vi Code'.Any city or county which requires a permit to construct,alter,
EE ¢ Q 0 improve,demolish,or repair any structure,prior to its issuance,also FLED,CONTR. LIC.NO. PLED,
m N esquires the applicant for such permit to file a signet)statement that TOTAL / PERMIT TO
a w w he is licensed pursuant to the Isrovisions ofthe Conte¢tors License
Law(Chapmr9(commencing with Section 7000)of Division 3 of the /,v 649 C4/11a431U
- a Business and Professions Code)or that he I,exanpt therctront and OTY. PLUMBING PERMIT FEE
r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TVP CONSTR.
u3L' by any applicant for a permit subjects the applicant loo civil penalty gLTER-DRAIN -WATER IEA.) 5.00
of not mom than five hundred dollars(S500)J: '5-ti,
❑ I,as owner of the properly,or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00 OCG GROUP RES.UNITS
their sole compensation,will do the work,and the structure rs not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00 X _ �t
Codes The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 So.FT FLOOR AREA TOTAL ACREAGE
himself or through]its own employees,provided that such improve
.- mems are not intended or offered for sale,if,however.the building GAS-EA.SYSTEM'-11NC.40UTLETS 6.00 �9UG i
or improvement is sold within one year of completion,the owner- /
n
builder will have the burden of proving that he did not build Or im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
1' Drove for purpose of sale.). RES IND' CON Ps Other
��pp I,as owner of the property,act exclusively contracting with - INDUSTRIAL WASTE INTER. 30.00 El El11 0 ED
Iica "d contractors to construct the project(Sec 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL N0.
and Professions Code:The Contractor's License Law does not apply
In an owner Of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) • 1.000'aZ - 9 U' )91
s contracts for such projects with a contructods)licensed pursuant to et.
the Contractor's License Law. SEWER-SANITARY V-STORM EA,200ft/10.00 TRACT NO. PARCEL NO.f
L O I ant ezem Dander c. B.&P.C.per this
a . _M' reason S%e WATER HEATER W/VENT 6.00 G�
Owner r ' Dale WATER SYSTEM 5.00 /
ACC.DATE ACC.FILE NO.
WORK I 'COMPFNSATION DECLARATION WATER TREATING EQUIP. 5.00
{ I hereby affirm that 1 have a certificate of consent to self-insure,
v or a certificate of Workers'Compensa...n Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.CJ.
[:- Policy No. Contpony
O ❑ Certified copy is hereby furnished.
FIRE SPRINK ENERGY T 2
Z Z ❑ Certified copy is tiled with the city inspection division. MISC.- REFER TO ORD.
- O Applicantv E:] NE:] v❑ NE:]
r viIr 'CERTIFIC1EIEROMWORKERs' PERMIT ISSUANCE 10.00
FLOOD ZONE A.L.U.C.
W > COMPFNSATON INSURANCE
PLG.GONTR. LIC.NO. PLG.
.P (CL ClThis section need not be completed if the permit is for one TOTAL Y❑ N❑ V Ej N�
Z) Z b u n dred d o Bars IS 100)or less.)
U O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
W F mil is issued,I shall not employ any person in any manner so as to
.� Uw become subject to the Workers'Compensation Laws of California.
IS. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING SSD
} W NOTICE. TO APPLICANT. If,after making this Certificate of Ex- _
F Z caption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK _
provisions of the Labor Code, you must forthwith comply with FEE
r U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY _ AIR HANDLING UNITIOVER 10p00C.F.M.) 6.00 SEISMIC FEE / 7
' 1 hereby affirm that there S a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the w r for which tltis permit is issued(Sec. MICROFILM
3097.Civ.C.L fl HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)Lender's AddressFW, ELECTRIC
-'T I certify that l have read this application and stalt that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county •PLUMBING
ordinances and stale laws relating W building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to atter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
aboptmo
nM operty for inspection purposes.
( c o sa indemn' and keep harmless the City of MISC.- REFER TO ORD.
Cupa tit Iia ili[ies,j rents, costs and expenses whichCONST.TAXmaay ne me ay' I said City in (,C,cquence of the PERMIT ISSUANCE 10.00 granrn / MECH.CONT. LIG NO. MECH.
TOTAL TOTAL
Si al I/Contractor Uat
\..• INSPECTOR COPY
A )