09717 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
FGr'ILDIN$ r _fC-07F APPLICATION & PERMIT 09717
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S FLAN CHECK VALIDATION
NAME PHONE• QTY. ELECTRIC PERMIT FEE
OMTRACTORs
OUTLETS-SWITCHES-RECEP 10.00/1.00
ME �j
• f E (Iq / uc NAI) ? LIGHTING FIXTURES 10.00/1.00
"CONTRACTORS APPLIANCES-RESIDENTIAL 4.00 J"
CONTRAORES /I
C/ 1 A, f ZEHory b- PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCHE R ENG _ SPECIAL CIRCUIT 5,08 PERMIT VALIDATION
SS
ZIP rrEMP. METER,OR POLE INS. 20.00 n
APPLICANT'S MOTORS SEE FEE SCH. K
ADDRESS
SERVICE CHANGE 20.00
o o LICENSED CON'I'RAC'1 ORS DECLARATION TEMP.POLE 30.00
a
Or u I hereby a]I'ino that I am licensed under provisions of Chapter 9 ISSUANCE DATE
m a w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. DLG. MECH.
F w z Professions Cydc
dmny license is in full fo nd wC(e
Z o as- License Clan Yy .lV/ Lic.Numbur U
Q aa ;mc n a r s� Contactoi
a y E BUILDING PERMIT
CE a w a OWNER-BUILDER DECLARATION INFORMATION
Da " MISC - .REFER TO ORD
w LL I- I hereby affirnn that I am exempt from the Contractor's License .
.. 00 Law for the followingreason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION
Code:Anyeity orcounty which requiresa permit to construct,after,
ic a Q Q improve,demolish,or repair any'structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
0 u requires the applicant for such permit to file a signed statement[flat TOTAL PERMIT TO
u w m he is licensed pursuant to the provisions of the Contractor's License _
F z r
Law(Chapter 9(commencing with Section 7000)of Division 3 of the NJe
- a Itlniness and Professions Code)or that lie is exempt therefrom and QTY. PLUMBING PERMIT FEE
W F o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n ; T by any applicant for a permit subjects lite applicant tea civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500),):
❑ 1,as owner of the property,or my employees with w....as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will filo the work,and the structure is not OCC.GROUP RES,UNITS
intended or offered for sale (Sea 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself re through his own employees,provided that such imProve-
himselfents re not intended oro ffcrcdfbrsalallho what suhein ,ding GAS-EA.SYSTEM-11NC.40UTLET$ 6.00
or improvumeut 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- BUILDING USE
Prove for purpose of sale.). INDUSTRIALWASTE INTER. 30.00 RES IND CON PB Omer
❑ 1,as owner of line property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
lain Professions Code:The Contactors License Law does not apply
to an owner al'properly who builds or improves thereon,and who LAWN SPR INKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sea ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
n
Ower Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO,
WORKIiRS'CO%fPEN5ATIONDECLARA'T'ION WATER TREATING EQUIP. 5.00
1 hereby alfirm that 1 have a certificate of cons..to self-insure.
or is certificate of Workcn Com@ gsaIien Insurance,or a certilarl -ZONING ENG.SITE NO.
copy the uL Sec. 500,Lub vC>� jT. /-"I�
Poll N��.�yCompan, --b U'l`
QCetlified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z -Z Certified copy is filed with file city inspection division.
O Applicant MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
� y CERTIFICATE 0I7 EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOOZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.'' v❑ N❑ v ❑ N❑
CL Z IThis section need not be completed if the permit is for one TOTAL
hundred doll...(S 100)or Ic1Q
U O 1 certify that in the performance al the work for which this ,c,- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
Q_ H mit is issued,I shall not employ any person in any nmnner so as to
U become subject to the Workers'Compensation Laws of Czfifornia.
UJ C. DateApplicant ALTER OR ADD TO MECH. 5.00 BUILDING
} To NOT ICE TO AI'PLICANI': If,alter making this Ccrt ifiea[e of nix-
Z_ clnption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must fortllwlth comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OYER 10=C.EM.) 6.00 _ SEISMIC FEE
1 hereby uffinH'that there is a construction lending agency for EXHAUST HOOD(WITH.DUCT) 5.00
the 3097 )
LCiv�C� 11 of tire work for which this permit is issued(Sc,,. ICROFILM
. / HEATING UNIT(TO 100,000 B.T.U.) 8.00 (/'o
,Lender's Name - HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I C
Lundcr's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COUP(3 H.P.or 100,000 B.T.U.) 6.00 �-77
hereby authorize representatives of this city to enter upon the BOILER-COMP (OVer 100,000 BTU)SEE FEE SCH. MECHANICAL C j gt/
above-mentioned property for inspection purposes.
lWe) agues to save, indemnify and keep I..rnless the City of MISC.- REFER TO ORD.
CuperlifTo gains[ liabilities,judgments, costs and expenses which Q u CONST.TAX
may (n y way accrue uinst said City in consequence of the PERMIT ISSUANCE 10.00
gra Of this TIC
'� -(/ MECH,CONT. LIC.NO. MECH, y
460YTOTAL oCl�u TOTAL
Igoe of p Ican[/Contras or Date
INSPECTOR COPY
t