9187 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION • PERMIT NUMBER
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APPLICATION & PERMIT _ 9187
ADDRESS BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S P PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
• DNE
NAME RAcroRs OUTLETS-SWITCHES-RECEP 10.00/1.00
t ILIGHTING FIXTURES 10.00/1.00
DRESSTRACurs
ADDRESS PPLIANCES-RESIDENTIAL 4.00
A
'.q<5' PHONE i �0 PANELS 10.00 DATE OF APPLICATION
OORRCHITECTPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG
SPECIAL CIRCUIT 5:QQ PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 20,00
APPLICANT's MOTORS SEE FEE SCH. /x( ,✓•tLrL
ADDRESS I
SERVICE CHANGE 20.00
w o O LICENSED CON'T'RACTORS DECLARATION TEMP.POLE 30.00 I�-JA(
U U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE l
"' (commencing with Section 7000).f Division 3 al'the Resines-and
rA Q a BLDG. ELECT. PLG. MECH.
F w Z 'Professions Code,and my license iso full for'•and effect ❑ ❑ -❑` '1
z o m - License Class 3 Lic.Nanha
z F m Dale CIO
Contractor
BUILDING PERMIT
¢o IT srIT OWNIi R-B UILUER UIiCLA RATION - INFORMATION
wg; LL y 1 hereby mfinn that I am cxempl lion. the Contractor's License MISC.- REFER TO ORD VALUATION $/FT.
F 0 4 Law for the following reason. 7031.5,Husincss and professions PERMIT ISSUANCE 10.00
Cade:Any city or county which raryims a peon d to construct,alter. ))�(
Q improve,detiolisli.or repair any structure,prior to its issuance,also ELEC.CONTR. LIG.NO. ELEC. I NT
as
iL O u requires lire applicant tie such permit to file a signed slmemenl that TOTAL PERMIT TO
a w m e is licensed pursm uant the provisions of the Contractor's License -
� zQ hLaw(Chapter 9(commoncing with Section 7000)of Division 3 of lire �.�� (Y„� �,
i D Business and Professions Code)or that he is exempt therefrom and GTY. PLUMBING PERMIT FEE _7./ K/L -
IC I_ o the hasls for the alleged a x,n.ption.Any violation.(Suction 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant Loa civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of Rol more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered lin, .to (Sec. 7044, Business and I'rofew..z DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's Locnse Law docs not apply to an owner of _ -
propertywhobuildsorimprovesthereon,:rad who docs such work FIXTURES-PER TRAP 5.00 So,FT.FLOOR AREA TOTAL ACREAGE
•• ,himself or through his own employees,provided that suchimpro.e-
ments are not intended or offered for sale.If,however,the buildingGAS-EA.SYSTEM-I1NC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 IEA) 200
buildei will have the burden of proving that he did not build or ins- - . - . .
- BUILDING USE
prove Joe purpose of sale.)' INDUSTRIAL WASTE INTER3000 RES IND CON PB Omer
❑ 1,as owner of the property,am exclusively'contracting with . .
❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:Tile Contractor's 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 for such projects with:I comrxcmdsl licensed Pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
tire Contractors License Law. TRACT NO. PARCEL NO.
❑ I am 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.
NORKI;P,S'COMPGNSAI'[ON DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate Life...pent to self-insure. ZONING
or a certificate pf Workets'Compelaction Insurance,or a CertifiCd- ENG.SITE NO.
e.pynhereof(Sec.3800,Lab.C.).
• •Pelicy.'No. Company /5
=�❑:Grli)'eit pyi5l.er' f is it.
FIRE SPRINK ENERGY T34
-Z Z• ❑ Cerp 1''C copy, I d wit she ciFy inspection division. .MISC.- REFER TO ORD.
•APPinn1 - Y❑ N❑ V ❑ N❑
,ez - x PERMIT ISSUANCE 10.00
U•- C1,41FICC0Ii F.N XA:MPTINS fROMWORKCRS' FLOOD ZONE A.L.UF.
W � COMPENSATION INSURANCIi PLG.COrvrR. sec.rv0. PLG.
(ITis action need not be c.mpleteal if the permit is for one TOTAL V❑ N❑ Y ❑ N❑
hundred d.11ars($1001 or less.)
U O I certify that in the perl'ornumce of Ilia work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mil is issued,I shall not employ any person in any nanner so as to
U become subject to the WorkerF Con.pensation Laws of California.
X
U a Dine-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING 42
>_ N NOTICE 'f0 APPLICAN' In
1: If,after aking this Certificmc of Ex- of -
F 2 emplion,you should become Subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK q}
provisions of the Labor Code, you must forthwith comply will
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 FEE o
CONST'RUCI'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 6.00 - SEISMIC FEE
I hereby affirm that there is a construnion lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this Permit is issued(Sec. MICROFILM ..yr
3097,Cie C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC > ,
1 certify ilia,1 have read this o comply and style that the shove VENTILATION FAN (SINGLE) 4.00
ordinances n correct. I agree to comply with all city and county PLUMBING ordinances and state laws relating to building construction. and BOILER-COMP 13 H.P.or 100,000 B.T.UI 6.00
hereby authorize representatives of this city to enter upon lire �..-
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 RTU)SEE FEE SCH. MECHANICAL
(We) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
qy
rf •sins. hab n"' 'udb'ml=nts, Costs and expenses which CONST.TAX
n any ay ac g' nst 'id City in consequence of the PERMIT ISSUANCE 10.00
ing Of Is per MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Sigmt re of ApplicalratiCafilractor Data
INSPECTOR COPY
I