8363 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
AOD96SS �+ ) APPLICATION & PERMIT 3b3
G7 UI LDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER S I PLAN CHECK VALIDATION
NAME 4 �(� OTY. ELECTRIC PERMIT FEE
• �.\Y/[� x PHONE
NDNTRA roes OUTLETS-SWITCHES-RECEP 10.00/1.00
E Lie, LIGHTING FIXTURES 10.00/1.00 C
CONTTRA TORS A APPLIANCES-RESIDENTIAL 4.00
ecoj PRO_ 3D SOOD PANELS 10:00 DATE OF APPLICATION
OR IT T PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE
ENGINEER
Lac.rvo. SIGNS TRANS. 3.00
ADDRESS ENG, PERMIT 55,00 PERMIT VALIDATION
zlv TEMP.METER OR POLE INS. 20.00
ADDRESS T$ MOTORS SEE FE -SCH. ) S
A SERVICE ANGE 20.00 /
Woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00to
< U I hereby al'fum that I am licensed under provisions of Chapter 9 A ISSUANCE DATE
in Q to Icommmcing with Seclion 7000)of Divi'ion 3 of the Business and BLDG. ELECT, PLG. MECH.
D z Professions Code,un my license is in f ciJfuL ❑ ❑ ❑
o 0 m o Licensc Class Lia Nun b 7/�b
Date _ Cuntrad<
a x F
BUILDING PERMIT
¢ ¢ w a OWNIiR-BUILDER D2 ARATION
A O a INFORMATION
X g y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
a. o ¢ law for the following reason.(See 7031.5.Business and Professions - VALUATION S/FT.
Code:Any city or county which requiresa permit toconstrucl,alter, PERMIT ISSUANCE ..10.00
Qimprove,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
DLL requires the applicant for such permit to file a signed sLdentenl that E TOTAL 6
n w m .Ire is licensed pursuant to the provisions of Os Contractor's Licensc PERMIT TO
Hzva Law(Chapter V(commencing with Section 7000)ofDivision 3 of the
a Business and Professions Code)or that he is exempt therefrom and QTV. PLUMBING PERMIT FEE
¢ H o the basis for the alleged exenhption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
dam by any applicant fooa permit subjects the applicant to a civil penally ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars JS5001J:
❑ I,as owner of tire property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UN ITS
their sole compensation,will do fire work,and the structure is not
intended or offered for sale(Sue, 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 5.00
Code:The Contr actor',License Law docs not apply to an owner of
property who builds or improves thercon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTALACREAGE
. himself or through his own employees,provided that such improve-
mentsare not intended oroffered for sale.if,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion are owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did mdghuild or ire- BUILDING USE
prove for purpose of sale.). mer
INDUSTRIAL WASTE INTER. a 30.00 RES IND CON PB O
❑ I,as owner of the property,am exclusively contracting will)
licensed contractors to construct lire project(Sec. 7044,BusinessLAWN 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 eontractorls)licensed pursuant to
,the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
x\❑ I am exempt under Sec.-,B&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner - Dale WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate oI consentto setGr,ure,
or a certificate of Workers'Compensation [nsur nee,or a ace 'lied ZONING ENG-SITE NO.
copy thereof(Sec 3800,Lab C.
Policy No. Company
O Cl Cetlil copy 6hereby lumished' FIRESPRINK ENERGY T 24
Z Z -Cenife co is filed with the city inspection division.
FO Applicant 4 MISC.- REFER TO ORD: YE] No Y ❑ NE]
� N (': FIC10/F OIa EXEMPFION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE aL.U.C.
W COMPI?NSATION INSURANCE; PLG.CONTR. LIC.NO. PLG. El NO
E] ❑
Il Se
0 (This clion need nut be completed if the permit is for one TOTAL Y N Y N
:3 Z hundred dollars(5100)or less.)
U O I certify that in the performance of the work for which this per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mil is issued,I shall not employ any person in any manner so as to
O w become subject to lire Workers Compensation Laws of California.
Is. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z emplion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you mwat 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
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
lire performance of the work for which this permit is issued(Sec MICROFILM
3097,Cie C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's
Name HEATING UNIT ER 100,000 B.T.U.)9.50 i'
Lender's Address ELECTRIC
Icertify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
mformmion n conceal I agree to comply with all city ucti county BOILER-COMP(3 H.P,or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and stale laws relating to building 1 c41 construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above mentioned properly for inspection purposes.
(We) ree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Caper noagainst liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may e : ly way accrue against said City in consequence of the
gran in Ethis penult MECH.CONT. LIC.NO. MECH.
°Tq` TOTAL
ign are of Applica o tractor Uate
• INSPECTOR COPY