09719 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING E5$ L07 APPLICATION & PERMIT 09719
4DOR
BUILDING -ELECTRICAL-PLUMBING -MECHANICAL
O NER' tT, PLAN CHECK VALIDATION
n ME /`•
PHONE QTY. ELECTRIC PERMIT FEE / 1
TRACTORS�Iy-
OUTLETS-SWITCHES-RECEP 10.0011.00
L/ AO)l see NS(? VDLIGHTING FIXTURES 10.00/1.00 � V
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
DD E55
PANELS 10,00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHE&TF7 P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH,OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
ZIP EMP.METER OR POLE INS. 20.00
ADDRESS
,y
AMOTORS SEE FEE SCH. K
ORE
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 y
X U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE GATE
H G m (commencing with Section]000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H w z Professions Co an m iceme is in full t r n
Z o m - Liccns �Ll,vs '-�r� Lic.Numbc� ❑ ❑ ❑
9 H Date Comom rIL
a rs ` BUILDING PERMIT
BE Q w a OWiNER-BUILDIiR DE LARATION INFORMATION
w ;ec H I herehy affirm that I am exempt I'ronl the Contractor's License MISC.- REFER TO ORD
Isoj Law for tire P.S.G.
e following r (Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 'VALUATION $/FT.
r - Code:Any cilyor county which requires a permit to construct,alter,
Qea Q 0 Improve,demolish,or repair any structure,prior to IIS Issuance,also ELEC.CONTR. LIC.NO. ELEC.
- O BE requires the applicant for such permit to file a signed statement Item TOTAL PERMIT TO
n w m be is licensed Pursuant to the Provisions or[lie Contractor's License -/
H z s- Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe `c("L/L
a Business and I'rofes.inns Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
o the basis for the alleged exemption,Any violation of Section 703 L$ STORIES TYPE CONSTR.
a3E by any applicant for it permit subjects the applicant do a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
o1'not more thin dive hundred dollars(S500),I:
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sole(Sec..7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
.
Code:'I'lie Contractor's License Law does not apply to in owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTALACREAGE
himself re through his own employees,provide)that such improve-merits building
himself
not through ted or employe ,provided
that such
building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the hurden of proving that he did not build or hit- RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
0 1,as owner of the property,am exclusively contracting will
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The 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 a contractords)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT No. PARCEL NO.
❑ lam exempt under Se,-,BAP.C.for this WATER HEATER W/VENT 6.00 '
reason
Owner Date WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO,
WORK I'RS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00
I heraby allirm that I have a certificate of consent to self-insum, ZONING
or a cemil'icme of Workers Compensation Insurance,or a certified ENG.SITE NO.
copy the 00,Lab. 1
I'I�i i N9�-` -19 mpanl
O �l Ce ti ed copy lshe 'by furnished. FIRESPRINK ENERGY T 24
Z Z ❑ C ri 'e copy is filed with the cit }......H".. division. MISC.- REFER TO ORD.
O AppliCan ch If CJ[ / Y❑ N❑ Y ❑ N❑
~ w �rV ,,- IPERMIT ISSUANCE 10.00
CC CFR'I'IFICATIi OF EXEMPI]ON FROM WORK ERS' FLOOD ZONE A.L.tLC.
LU 5 COAIPFNSAT10N INSURANCE PLG.CONTR. LIC.NO. PLG.
Z (This section need not be completed if the permit is for )Be TOTAL Y El N❑ v C] IN C]
hundred dollms(S IOD)or less)
0 O I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued.1 shall not employ any person in any manner so as to
O w become subject m the Workers'Compensation Laws of California.
ED Date Apphcand ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE;TO APPLICANT: If,after making this Certificate of Ex-
F Z cmption,you should become subject to the WorkerF 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 10)OODC.F.M.) 4.00
CONSTRUCTION 1.17NDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
rm
I hereby affithud there is a construction lending agency liter EXHAUST HOOD (WITH DUCT) 5.00 Zl/
the performance of the work for which this permit is issued(Sec. MICRORLM
3097,Cir.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 `W
Lender's Name
Lender's Address H EATI NG'UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that 1 have read this application and state Hitt 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-CDMP(3 H.P.or 100,000 B.T.U.) 6.00 f
hereby authorize representatives of this city to ender upon the BOILER-COMP (Over HOO,000BTUISEE FEESCH. MECHANICAL 4v
above•mentioned properly for inspection purposes. dq v
21,
ee to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cnogainst liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
m way accrue t m,a said City in consequence of ire
ghis permlt MECH.CONT. LIC.NO. MECH.
�i// g//- p r TOTAL a3✓ TOTAL
Siynat mnC AppleanlJO ntracdor Dote 9-.1
INSPECTOR COPY