8712 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
*DORESS
_ BUILDING-ELECTRICAL-PLUMBING -MECHANICAL 8712
-1 OWNER'S PLANCHECKVALIDATION
. I NAME OTY. ELECTRIC PERMIT FEE
M Al2 picc-o DEV PHONE 7A-1)
CONTRACTOR'S
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
M GO C>g.l Llc.rvo. - LIGHTING FIXTURES 10.00/1.00
ADTRACrofl•s
ADDRESS
APPLIANCES-RESIDENTIAL 4.00 ('
1
/IN ,r,PNE S�a2z PANELS 10.00 DATE OF APPLICATION
pgCHITECr PANELS I OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
• LIC.No. SIGNS TRANS. 3.00 TI'
Boo Ess ENG. SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 20.00
ARESMOTORS SEE FEE SCH.
ADDRESS
�P6 L,C �(.{� ,
13 •(, SERVICE CHANGE 20.00
o
M. z0(
r 1y LICf:NSCD CON'1'kACI'ORS DECLARATION TEMP.POLE 30.00
G v U I hereby uffinn thal I am licenxtl under provisions of Chapter9 ISSUANCE DATE
yA w (commencing with Section 7000)of Division 3 of the Business and
¢ n BLDG. ELECT. PLG. MECH.
r w - Professions Code,and m license is in full force and effect. ❑� ❑ ❑ ❑
' 0. -- - Liceue Class_�_4 i Cm Number�y'�7, 10r0
o m t ° Dam-5 's5 Comructor. .r„tE
a Y '+\, BUILDING PERMIT
¢ ta ¢
OWNER-BUILDER R-BUILDER DECLARATION
¢w o INFORMATION
X ;. v, I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u o a Law for the following reason.(Sec.7031.5.Businessand ProfessionspERM1T ISSUANCE 10.00 VALUATION S/FT.
� - Code:Any city or county which requires a permit to construct,alter, (,[,�
¢ ¢ G Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC. /v O
s w m M u. requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License ;e
F z i Law(Chapter9Commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ moo the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
Ate _ by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(5500)J: I�
O 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their Sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS Ij
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND- 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- .
trents are not intended or uttered lot
sale.If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
ar improvement is sold within one year of completion,the Oe owner- GAS EASYSTEM OVER 4 (EA.) 200
builder will have burden of proving that he d - . - . .
id not build or inr BUILDING USE
Prove l'or purpose of sale.). INDUSTRIAL WASTE INTER. ' 30.00 RES IND CON PB Omer
❑ I,as owner of the property,um cxCluslvely 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 Code, I'lie 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 enntracbn(s)licensed pursuant to
the Contractor'sors License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ Inns exempt under Sec.-,B.&P.C.for itis WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPFNSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a Certificate of conscm toself-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof 1 Sec.3900,Lab.C.).
Policy No.
Company
DCerticyisl ^
Va
FIRE SPRINK ENERGY T24
Z Z D Ceriievth/eidvson.
O Applicant
x
MISC.- REFER TO ORD. Y❑ N❑ v ❑ N❑
� y CBRI'IFI THOlt li%:M PI'ION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.CL -
CL Z 1'1'his section need not be completed if the Permit is for one TOTAL Y ElN❑ Y 1:1 "N
hundred dollars IS 1001 or less.)
U O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any Person in:my manner so as to
U become subject to the Workers'Compensation Laws of California.
C. Dam Applicant ALTER OR ADD TO MECH. 5.00 BUILDING S'0
} to NOTICE TO APPLICANT': If,after making this Certificate of fix-
� Z enpuion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
I rovisions of the Labor Code, You most foAtwith comply with FEE _
U such provisions or this permit smell he dee ned revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONS]'RUC'I'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE J �'
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) .5.00
lire performance of the work far which this Permit is issued(Sec. -MICROFILM
3097,Cie C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lenders Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 1
Lender's Name
ELECTRIC
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-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP IO no 100,000 BTU)SEE FEE SCH. MECHANICAL
above mentioned property for inspection purposes. -
(we) agree m save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cuperti o against liabilities,judgments, costs and expenses which CONST.TAX
may i a y w accrue gains[ id Ci in consequence of the PERMIT ISSUANCE 10.00
grant fthi I MECH.CONT. LIC.NO, MECH.
TOTAL TOTAL
Si a pl' t/ t Date
INSPECTOR COPY