6784 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
toH-DING APPLICATION & PERMIT
ADDRESS
UILDING - ELECTRICAL-PLUMBING-MECHANICAL 6784
rA
PLAN CHECK VALIDATION
OTY. ELECTRIC PERMIT FEE
MINMACTONs
NAME I OUTLETS-SWITCHES-RECEP 5.00/1.00
C04 9ACTOR SLIC.No. LIGHTING FIXTURES 5.00/1.00
aooREss
Co Actions PPLIANCES-RESIDENTIAL 4.00
dnME PANELS 5.00 DATE OF AP PLICATION
ARCHITECTS6.00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER
LIC,No. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
AODHEss
Z;pEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE BCH.
ADDRESS
SERVICE CHANGE 10.00 /�
o o LICENSYU CONTRACTORS DECLARATION Or�
mo u I hereby affirm that I am licensed under provisions of Chaplet
ISSUANCE DATE
Gw (commencing with Section 7000)of Division 3 ofthe Business BLDG. ELECT. PLG. MECH.
r m z Professions IC of I 1' se is in full for' n
ZOIC- License Class_(=.Qj.(�U Numher - - ❑ ❑
0 z r 0 Datc.g )_q�� Contractor -
Pq
`a y E " 25F GA O. BUILDING PERMIT
or w u OWNL'R-1UILDER DECLARATION INFORMATION
w0 A MISC.- REFER TO ORD
; w y I hereby affmm that I am exempt from the Contractors License VALUATION $/FT.
w0a Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 6.00
v, I Code:Anycity orcounly which reyuiresa permit to construct,alter,
Qa, Q 0 improve.demolish,or repair any SINCtat',pf1Or lO lis IS,Cance,,ISD ELEC.CONTR.' LIC.NO. ELEC.
w
- 0 re requires the applicant for such permit to ile a signed Statement that I TOTAL P gMIT TO
so C he is licensed pursuant In the pro 'ort (the Conirhdor's Llmisc
I- z,Q Law.(Chapter 9(roomcnci wit •etil 7000)of Division 3 of the -
Business and professions Co q t a t e is exempt therefrom and OTY. PLUMBING PERMIT FEE /
r 0 the basis for the alleged exvm to lay violation of Section 7031.5. TORIES TYPE CONSTR.
'AS�-' by any applicant for ape is O the applicant too civil penalty ALTER-DRAIN -WATER (EA.) 4-00
of not snore than five h i tars(5500).1:
❑ rare
owner yl'o a or my employcc,with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP' RES.UNITS
their sole compen5:�yo i,w do t m work,and the stricture is not
mended nr offrrrd for sal (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:'rhe 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 4.00 SO.FT.FLOOR AREA TOTALACREAGE
himself or through Ili,own employees,provided that ,,It im
arprove-
ments e not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4-00
or improvement is sold within one ycm of completion,the owner , GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving Ileus bcdid not build or int- RES IND C N PB Ort14r
prove for purpose ol'sulu.). INDUSTRIAL WASTE INTER. 20.00
❑ I,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. 5.00 --ASSESS O P CEL NO.
and Professions Code The Contractor's License Law Jars 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 contractorts)licenced pursuant to
Are Contractor's Liccn,c Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
❑ lam exempt under Sea ,B.&I'.C.for this WATER HEATER W/VENT 4,00
reason
Owner Darn WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARA I]ON WATER TREATING EQUIP. 4.00
1 hereby a((irnl that I have a certil cale of consent to sdhinsure. - ZONING
or a ecridicale of Workers' ni"n,ation homrn¢,i 'eHitied ENG.SITE NO.
copy thereoff. 500,I.0 .C.1.
Policy Nn, o
O ❑ Certilie lo_ ish• y Rm,on d. FIRESPRINK ENERGY T]4
y�,7Certzific r - Jed with lire city inspection division.0 ApI+Rc;ur y - MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
j= N CFR'I ICA'1'1:OF EXIiMPTION PROM WORKERS*
I PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C. '
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d 0 (This Section need not be completetd if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
Z) 2 h and rad dollar,(5100)or less.)
U O I certify that in the performance id the work for which.ihis per- OTY. &2ffhCAL.AERMJT FEE FEE SUMMARY
LL 1- mit is issued 1 0A not e...ploy any.person in any Ina..nor so as to
U Calif.'
ria.subject to the Workers'Compensation Laws of Califoia.
U to Date App cant ALTER OR ADD TO MECH. 4-00 G�, BUILDING
} Go NOTICE TO APPUCA I': I ftcr making this Certificate u(Bx-
? enito ion,you should ben neije- to the Workers Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor o e o most forthwith comply with FEE
U such provisions or thi. or It a e devoted revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONS ' 'I ON LENDING AGENCY AIR HANDLING UNITIOVER 10MC.F.M.) 5.00 SEISMIC FEE
I hereby fir t11't there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of lite work for which this permit is issued(Sec. MICROFILM
3097.Civ C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Address A EATI NG UN IT(OV ER 100,000 B.T.U.)7.50 ELECTRIC
Lender's
Icertify that I have read this application and state that tie above VENTILATION FAN (SINGLE) 3.00
Information is correct. I agree to comply with all city and county BOILER-COMP 13 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby au0mrize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We)fily'
save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Coo liub dies,)u mems, costs and expense,which CONST.TAX
C toy aL a agair(st)s.id City in consequence of thePERMIT ISSUANCE 3.00g anH g nL IVJV`/,. MECH.CONT. LIC.NO. MECH.
' TOTA (/Y'V✓/ TOTAL '--'
Signa u e r Applitvnl/Contractor ateLaK
INSPECTOR COPY