09746 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING
APPLICATION & PERMIT 09746
'ano�� � n , !'�� BUILDING - ELECTRICAL-PLUMBING -MECHANICAL
T O E S t ` PLAN CHECK VALIDATION
•
'NAME �r �^ QTY. ELECTRIC PERMIT FEE
\ `! l y FHONE� `� (
CONTRACTORS
NAME UTL ELS-SWITCHES-RECEP 10.00/1.00
LIC,NO. LIGHTING FIXTURES 10.00/1.00
CONTH ACTOR
ADDRESS PPLIANCES-RESIDENTIAL 4.00
ADORE
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
coo Ess ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.0 Tti -
AMOTORS SEE FEE SCH.
DRESS ESS
ADDR
SERVICE CHANGE 20.00
G� p
o O LICENSED CON'I'RACTORS DECLARATION TEMP.POLE 30.00 //�O/d
Se u V I hereby affirm that I atm licensed under provisions of Chapter 9 ISSUANCE DATE
HZ,"' (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
Fi Professions Code,and my license is in full force and effect. ❑ ❑ EJ
o w - License Class Lic.Number
o In r w Date Contracmr
m f BUILDING PERMIT
a w u OWNER-BUILDFR DECLARATION INFORMATION
a. 0A - MISC.- REFER TO ORD
w 3 LL I- I hereby affirm that I am exempt from the Contractor's License VALUATION
H n o J Law for the following reason(Sec.7031.5,Business and Professions -PERMIT ISSUANCE 10.00 6 "�
Code:Anycityorcounly which requiresa permit to construct,alter. -
M2 a o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEG /u'
ca - O LL requires the applicant for such permit to file a signed statement that TOTAL 0.0 PERMIT TO
wm he is licensed pursuant to the provisions of the Contractor's License
H i Law(Chapter 9(commencing with Section 7000)o'Division 3 of the +��e�� C LaG 7
a Business and Professions Code)or that Ile is exempt therefrom and QTY. PLUMBING PERMIT. FEE /
M F o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
ateT by any applicant fora permit subjects the applicant tozcivilpenxlty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars 65001.):
❑ I,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.CROUP RES.UNITS
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:1'lie Contractor's License Law does not uPlily 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-
mems are not intended or offered for sale.If.however.the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
OF improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4(EA) 200
builder will have the burden of proving that h - . - . .
e did not build or ire- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. -30.00 RES IND CON Pe Omer
CI 1,as owner of the 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.
and Professions Code: the Contractor's License Law does not apply
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a conlraclorts)licensed pursuant to
the Contractor's License Law. SEWER-SAN ITARV-STORM EA-200ft/10.00 TRACT NO. PARCEL NO.
C❑ml am cxem udrS . ,B.&PC for this WATER HEATER WIVENT 6.00
\. Ownc,J A 1 WATER SYSTEM 5.00
T �tr1I1/11�[(1 / ACC.GATE ACG FILE NO.
R-L nfP licl.n RATION WATER TREATING EQUIP. 5.00
Ihe by affirms at Iv. certificate ofcnnsent to self-insure.
Or a certificate of W r 'r5 Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.38 Lab.C.). ,
Policy No. Company
O ❑ Certified copy is hemby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certil'iCd copy is tiled with the city inspection division. R TO ORD
F
MISC.- REE .
O Applicant Y❑ N❑ Y ❑ N❑
� w CI:RTI 171 CAV E"O F Ii X EM PT ION F RO M WOR K E RS' PERMIT ISSUANCE 10.00 FLOOD ZONE , A.L.UC.
W COAIPENSWION INSURANCE PLG.CONTR. UC.NO. PLC.
0- o (Phis section need not be Completed if the pernit is for one TOTAL Y❑ N❑ Y E] NEI
D Z hundmd dollars IS 100)nr less.)
U O 1 ceNlfy that in the performance of the work I'or which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner so as to
U become subject W the Workers Compensation Laws of California. s
0.Do
Date-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE"1'0 APPLICANT: If,after making this Certificate of Ex-
F Z emption,you should become Subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the labor Code, you must forthwith comply with FEE
U such provisions of this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10, OOC.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the 3097,performance
CivC Ince of the work for which this permit is issued(Sec. MICROFILM
HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT 100,000 B.T.U.)9.50 do
Lender's Address ELECTRIC
I certify that I have read this application and rWc that the above VENTILATION FAN (SINGLE) 4.00
infornatior 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 (Over 100,000BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to iiave, inkrTM 1j and keep harmless the City of MISC.- REFER TO ORD.
Cuperli agai 1 habilflus,judgfnents, costs w'd expenses which PERMIT ISSUANCE 10.00 CONST.TAX
FT i I y en a B4'airr�(st said City in Consequence of IIIc
gr if ,u this I r it, MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL -
Si au PI (C Date- -
INSPECTOR COPY