8216APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALLPOINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING-ELECTRICAL-PLUBING-MECHANICAL8216
PERMIT NUMBER
BUILDING
ADDRES
Ow 'S
PHONE
QTV. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
NOMERAc oRs
OUTLETS-SWITCHES-RECEP 10.00/1.00
�y p21'. rvD. CQ
DATE OF APPLICATION
LIGHTING FIXTURES 10.00/1.00
CONTRACTons
ADDRESS
O�( �� PH0
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
certec
on
ENGINEER
L.C. No.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH OR ADDRESS ENG.
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
rrEMP. METER OR POLE INS. 20.00
` ZIP
AR
Ess
ADDDDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
'3�T�s
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
License Class, - • - Lie. Numb v - M
ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
❑ ❑ ❑ ❑
,
' Date i - --,,41 contractor
BUILDING PERMIT
INFORMATION
OWNER-BUILDIiR DECLARATION
I herebyMISC.-
affirm flim 1 mn exempt from the Cons and Pro License
Professions
Law: Any following rtywhih requirs a permit to construct,
Code: Any city or county which permit tocronsuanc alter,
REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
ry,
$/FT.
ELEC. CONTR. LIC. N0. ELEC.
TOTAL
improve, demolish. or repair any shin lure, prior to its issuance, also
Structure,
herequires the applicant for such permit to file a signed statement that
he is licensed pursuant en the provisions of the Contractor's License
(Chapter with Section the
Jam/
PERMIT TO
r+/ /
Business and Professions
Business and Professions Code) or that lie is exempt
is exempt therefrom and
de) therefrom and
QTV. PLUMBING PERMIT FEE
6
J rV
i
the basis for the alleged exemption. Any violation fSccti.n malty
by any applicant fora permit subjects the applicant toacivilpenalty
of not more than five hundred Dollars (S500)):
em):
❑ I, as owner of properly, or my employees with wais not
their sole compensation, will do the work, and the structure is not
STORIES
TYPE CONSTR.
)
ALTER-DRAIN-WATER(EA.) 5.00
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Codc: 'fltc Contractor's License Law does not apply to an owner of
FIXTURES - PER TRAP 5.00
property who builds Or Inmroves thereon, and who docs such work
himself or through his own employees, provided that such improve-
ments are not intended or offered for sale. If, however, the building
SO.FT. FLOOR AREA
TOTALACREAGE
GAS- EA. SYSTEM- 1 INC. 4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im.
prove for purpose of sale.).
❑ 1, as owner of the property, am exclusively. contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB Omer
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project IS". 7044, BusinessLAWN
and Professions Code: The Contractor's License Law docs not apply
to an owner of property who builds or improves thereon. and who
SPRINKLERS- 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts for such project, with a contructo6o licensed pursuant to
the Contractors License Law.
SEW ER -SANITARY -STORM EA. 200ft /10.00
TRACT NO.
PARCEL NO.
❑ tont uxumpt under See. ,B.&P.C. I'or this
Pease,
WATER HEATER W/VENT 6.00
Owner Dale
WATER SYSTEM 5.00
ACC. DATE
ACG FILE NO.
WORK ERS'COMPFN'SATION DECLARATION
WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self -insure.
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof(Sec 3800, Lab.C.).
Policy No. Company
FIRESPRINK
Y ❑ N�
ENERGYT-24
Y [:] N[3
❑ CerliEedcopvl+herebyfurnished.
❑ Certified copy is fled with the city inspection division.
Applicant
MISC.- REFER TO ORD.
CERTIFICATE 017 FXEM 1) PION FROM WORK ERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A. L. U.C.
(704131,1SATION INSURANCE
1'Hiis section need not be completed if the permit is for one
PLG. CONTR. LIC. NO.
PLG.
TOTAL
Y ❑ N E1
Y ❑ NE)
hundred dollars IS 100) or Iess.I
I certify that in the ppfannince of the work for which this per-
mil is issued, I shall not ��[[nnplay`imZ person in any manner so as to
become subject to life WorlRr Com ensa lion Laws of alifo nia.
[)at,: Z llxd Applicant !
CITY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
/7
ALTER OR ADD TO MECH. 5.00
NO'PICE TO APPLICANT: If, a er making this Cerlific to of Ex-
APPLIANCE 5.00
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
PLAN CHECK
FEE
p
30
/ _
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT(OVER I0,000C.F.M.) 6.00
SEISMIC FEE
CONSTRUCT ION LENDING AGENCY
I hereby affirm (hit! there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work lin which this permit is issued (Sec.
3097, Civ.CJ,
MICROFILM
'
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address
HEATING UNIT (OV ER 100,000 B.T.U.) 9.50
ELECTRIC
VENTILATION FAN (SINGLE) 4.00
1 certify that I have read this application and slate that the above
information is correct. 1 agree to comply with all city and county
ordinances and slate laws relating to building construction, and
PLUMBING
BOILER-COMP(3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter open the
above-mentioned property for inspection purposes.
(Wagree io save, indemnify and,keep harmless the City of
Cu e) pertlno against liabilities, judgments, costs y)td ptoses which
1 'n an way accrue i y
ly I y y ngainsC said t iD 'on � octet of De
g x'ng hi er iL
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 10.00
MEECH. CONT. LIC. NO.
MECH.
TOTAL
3�
a�j _
Sib a ppli nt/Contractor toKD
INSPECTOR COPY