C9180 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENT]FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
.� ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANIOAL
y� PLAN CHECK VALIDATION
CITY. ELECTRIC PERMIT FEE
vHONE
NAME AgELIS OUTLETS-SWITCHES-RECEP .10.00/1.00 PLAIf'�D
LIC.No. LIGHTING FIXTURES 10.00/1.00
A'DDRESST RS - APPLIANCES-RESIDENTIAL 4.00 j1,1 17 1f185
PHONE PANELS 10.00 DATE OF APPLICATION
\
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK F€E a InR.C.NO.
ENGINEER City Ot LOP V
uc.No. SIGNSTRANS. 3.00 `
ADDRESS NG' SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
PLICA S CA
A MOTORS SEE FEE SCH.
C,t SERVICE CHANGE 20.00 C
, i
w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 - ry/�(0
a o I hereby affirm that I am licensed under provisions of Chaptcr 9 ISSUANCE DATE
vii a (commencing with Section 7000)of Division 3 of the Business and
< BLDG. ELECT. PLG. MECH.
0 Professions Cod d my license is in full f e and effect
oi w Q� License Class_Lic.Number
•v„F w H w Date Contractor
¢ Y ¢ a /-' OWNER-BUILDER DECEARATION BUILDING PERMIT
o a U INFORMATION
w ; LL 1- 1 hereby affirm that I am exempt from the Contractor's License IMISC.- REFER TO ORD
uOj Lawfor'thefollowing maxim. 7031.5,Business and Professions VALUATION S/FT.
- _ PERMIT ISSUANCE 10.00
vs
Code:Any city or county which requimsa permit to construct,alter, 7�
Q ¢¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O¢ 1(91
requires the applicant for such permit to file a signed statement that TOTAL
wm m lm is licensed pursuant to the provisions of the Contractor's License PERMIT TO
Fz >
Law(Chapter 9(commeneingwith Section 7000)ofDivision 3 ofthe
a Business add 1'n,l'cssions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE (�^/ '7
1 o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES T PE CONSTR.
a ; m by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars(S500).): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole ebmpeosi tion,set]]do the work,and the structure is not
intended of offered for sale(Sec 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:Thr'Contmctm's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own ca,doyeos,Provided that such improve-
ments
mprovements are not intended or offered for sale.ll',however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
F or improvement Is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES LAD CON PB Omer
❑ I,as owner of the property,no exclusively contracting with ❑ El 11licemsed'c'ontractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSOTWARCEL 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
cortmets for such projects with a mntructons)licensed pursuant to SEWER-SANITAR V-STORM EA.200ft/10.00 _
i the Contract.,'s License Law. TRACTNO. PARCELNO.
�. ❑ 1 an exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 6.00
1 reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
.'WORKERS'COMPF.NSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ''I' ` ZONING ENG.SITE NO.
^ ora certificate of Workers'Compensation Insurance,or a certified
copythereof(Sec.3800,Lab.CJ. 4
r Policy No. Company �A.� K
Z, ❑ CertiOcd 'opy where f th FIRE SPRINK ENERGY T-24
Z Z Ao 4P,Z s fi w th cdy inspection division. MISC.- _REFER TO-ORD.D. v N v N
0 ❑ ❑ ❑ ❑
CCN P PERMIT ISSUANCE s I' 10.00
� - I C.R II%COCOMPENSATION
WORKERS' FLOOD ZONE A.L.UL.
W / needntbeco INSd if the PLG.CONTR. .LIG N0. PLG. v❑ N❑ Y❑ N❑
❑ --(I his section need not be completed if the permit is for one TOTAL
1 Z hundred dollars IS 100)or less.)
L) 0 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
p LL U alit is issued,I shall not employ any Person m any manner eo as to
L become subject to the Workers'Compensut ion Laws of California.
I 0- Date Applicant BUILDING 40OJ=
} to NO I'ICI?TO APPLICANT:If,after nnaking this Certificate of fix- ALTER OR ADD TO MECH. 5.00
F Z emption,you should become subject to the Workers'Compensation APPLIANCE k 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=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER'10=C.F.M:) 6.00 SEISMIC FEE ZO
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Ev.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name "`-
Lender's Address - HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that l lavd}ead thisapplication and state that the above VENTILATION FAN (SINGLE) 4.00
i
information n correct.I agree to comply will,n all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING '1 '
liceby
ordinances and , , laws relating to building construction, and
hcmby authorize represcn nativesof"to is city es mvcr upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned ntionI property f r�spection purposes
(WI.) all to save, ' dem ify and keep harmless the City of MISC.- REFER TO ORD. ti's
ertin amst ie gments, c is and expenses which CONST.TAX
i may 'n y a e h t said Cit in consequence of the PERMIT ISSUANCE 10.00
g' ti hs per h. MECH.CONT. LIC.NO. MECH, n l
Q TOTAL \ TOTAL
m plie a or
Date
/j' , INSPECTOR COPY "`