09715 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY '
BUILDING PROJECT lDENTIFICATION PERMIT NUMBER
APPLICATION & PERMIT
BUILDING
_ 09715 q r
ADDREE$. IL 9 i! 5
'I 'f/ BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
j1 OWNER'S I PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
'F FhW
P-ON
i • MT"^croRsC / OUTLETS-SWITCHES-RECEP 10.00/1.00 `I/ryt����/V.
'P,(, f L Ue.FeLIGHTING FIXTURES 10.00/1.00 J�'
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
NTRAC �q-
(/ ` T-Ory PANELS IO.00 DATE OF APPLICATION
ARRCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
' LIE.No. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ADDRESS ryiAPPLICANT'SMOTORS SEE FEE SCH. K (�P'(11Y•�••��
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATIONTEMP.POLE 30.00
a o. I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
y z aL (commencin with Section 7000)of Division 3 of the Business and a g H. BLDG. ELECT. 1 PLG. MECH.
F D i Professions Coppgmyyll Ilqqy license is in full fo - RMP
❑ ❑ ❑
ZLicense Class Lia Numbe ' /
ccoametTlI
ato
r E -a Cfft BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILDFR DECLARATION
a o at u INFORMATION
w g LL h 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
¢_ 0 ¢ Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city or county which requiresapermit to construct,alter,
at¢ a o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC.
w
- C ¢ requires the applicant for such permit to Ills u signed statement that TOTAL PER T TO
La z" he is licensed pursuant to the provisions of the Contractor's License Mf=-
i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthc
¢ Business and Professions Cock)or that he is exempt therefrom and QTY, PLUMBING PERMIT FEE
f ¢ a
¢ I- o the basis for the all r a exert soon.Any violation of Section malty STORIES TYPE CONSTR.
n �� by any opplicam fora ponnit.vubjcnsthcupplicunnoo civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(55001.1:
❑ I.as owner of the Property,or my entployces with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole cont pensution,will do the work,and (lie structure is not
intended or offered! for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code The Contractor's License Law docs notApply to an owner of
Property who builds or intprovcs thereon,and who does Such work FIXTURES-PER TRAP 5.00 SO.ET.FLOOR AREA TOTALACREAGE
himself re through his Awn cinplo lot s provided thin such impntvc
himself
not ing-A des oro ifcrcdforsalc.11',howhat s He building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold walao,one year of completion, the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will hive the burden ofproving that he did not build or int- BUILDING USE
prove for purpose of sale.). INDUSTRIALWASTE INTER. 30.00 RES IND CON BE Omer
❑ I,as owner of the property,wm exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Coda The Contractor's License Law does not apply
to an owner of property who builds or intprovcs thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for suchprojects with acontractors)licensed pulsation to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under See.-,HAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACG FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby infirm that 1 have a certificate of consent to self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy there Se 800.Lab.0). -1 '
PoIp N4 �lUl Compant ffIoa,Lf6
-PP�Certified copy ishereby' unshed. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified,copy is fled with the city inspection division. MISC.- REFER TO ORD.
0 Applicant Y ❑ N❑ Y ❑ N❑
L y CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.C.
Du > COMPENSATION INSURANCE PLG.CONTR. u0.NO. PLG_
CL 13 (This section need not be completed if the permit is for one TOTAL Y[:] N❑ Y E] N❑
hundred Rollins IS 100)or less.)
U O 1 certify that In the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mil is issued. I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: If,alter making this Certificate of Ex-
F 2 emption,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U .such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M,) 4.00
V CONSTRUCTION LENDING,AGENCY AIR HANDLING UNIT(OVER 10MOC.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a comstntction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,CF,C.), HEATING UNIT(TO 100,000 B.T.U.) 8.00 U)�
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 44 U
.
it is correct. 1 agree to comply with all city and County PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorirc representatives of this city to enter upon the BOILER-COMP lover 1000OOBTUISEE FEESCH. MECHANICAL 'a
above-mentioned properly for inspection purposes.
(We) all . to save, indennil'y and keep harmless the City on MISC.- REFER TO ORD. u CONST.TAX
Cuperfi a just liabilities,judgnwnts, costs and expenses which
may i) an way uceru I'mo ",it City in emtsequence of the PERMIT ISSUANCE 10.00 d
gran fug o'Oti.s perm] f MECH.CONT. LIC.NO. MECH.
O - TOTAL a 7 `. TOTAL
.jgnatur pli Contractor Dale
INSPECTOR COPY