6785 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDINGAPPLICATION & PERMIT
ADRESS 6785
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
. 20
E 'S PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
i PRDNE
CONTRACTORS UTLETS-SWITCHES-RECEP 5.00/1.00
III)i 44& 10
uc.No. LIGHTING FIXTURES 5.00/1.00
R CTOR PPLIANCES-RESIDENTIAL 4,00
ADDRESS
PRDNE PANELS S.00 DATE OF APPLICATION
n H r SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
NGINEEn
uc.No. SIGNS TRANS. 3.00 '
AAHCHOR UORESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00 ^ �"k^'�•_
Arrs if 11[11 MOTORS SEE FEE SCH. K /
ADDRESS
SERVICE CHANGE 10.00
'02 LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE GATE
,a <w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. ECH.
F w z Professions Code ad y cense is in full fare n
Z O- - License Class_ - Lic.Number e ❑ ❑ ❑ Ly
o H w Date Contractor
a Y F BUILDING PERMIT
re ur m er OWNER. UILDER DECLARATION INFORMATION
woAU MISC.- REFER TO ORD
S LL H 1 hereby'affirm that I am exempt from tire Contractors License VALUATION
H .. O J Law til.the following reason.(Sec.7031.5,Business and pro fessions PERMIT ISSUANCE 6.00 $/FT.
Code Any city or county which requires a permit to construct.allcq
ar an Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
0 K O u requires theapplicant for such permit to file a signed statement that TOTAL PERMIT TO
K
m hr is Cliitl)te pursuant Io the provisions of the )of[)ictora I-icensc
' r Law lChlgater'1(conunnming wits Srpion 70001 of Division3 of the
a ' Ousinesv.1111 PO'Nssions Code)or that he is exempt thercGmn and QTY. PLUMBING PERMIT FEE
Imo- Oo the basis lot the alleged exemption.Any violation of Sectiori 7031.$ STORIES TYPE CONSTR.
n � � by any applicunl lot a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not nmre(hon five hundred dollars(5500T)
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compmlulion, 'll J Ie w k,and the structure is no'
intended or offered for r c ( 704 , Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:'flu,Contractor's Li •ns w d es not apply to an owner of
property who builds im o s eon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through con m oyees,provided that such improve
mems are not me c Bred for sale.If.however,the building GAS-EA.SYSTEM-11NC.4 OUTLETS 4.00
or imp ovcme m1 with one year of completion, the owner- GAS-EASYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im . RES IND CON PB omen
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with E] E] C] ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions("ode: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such projects with a contract.,(,)licensed pursuant to
the Con(mmu,'s License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I;un exempt under Sea ,li.&I'.C.tar Ibis WATER HEATER W/VENT 4.00
m1l nI
(/W11ef 1>ate WATER SYSTEM 4.00 ACC.DATE ALC.FILE NO.
WORK HRS'COMPBNSA'IEON DECLARATION WATER TREATING EQUIP. 4.00
1 hereby atfinn thal I have a c"Ob"le of consent to S,IGinsure' ZONING ENG.SITE NO.
certificate of Workers'Compensation Insurance or u certified-ua o I• •I ! e ! L.b.C.).
P �npany
0y e < I herd fu nide FIRE SPRINK ENERGY T-24
F O �y(C 'li led o e II I t 't inspection division. MISC.- REFER TO ORD. Y ❑ NNE] y ❑ N❑
(p1TaI'
cc6CERTIPICAI' 01:EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU > CO PFN'SATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL 0 (Phis section nee not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
0 Z hundred dollais($10 )o.less.)
U O 1 certily that in the performance of the work for which this per. QTY MECHANICAL PERMIT FEE FEE SUMMARY
1L H mit is issued,I shall not Tapley any person in any manner sa as to
U become subject le the W Ikepi Compensation Laws of California.
LU Dam tppl eajrt� ALTER OR ADD TO MECH. 4.00 BUILDING
} N NO I'ICI: Ilt AI' CA I' a ter making this Certificate of Ex-
F Z common, u or
or jecl to Ole Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions o the Ia s Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed rrvekW. AIR HANDLING UNIT(TO 10p00C.F.M.) 3.00
AIR HANDLING UNITIOVER 10=C.F.M.) 5.00 SEISMIC FEE
f.(INS"IR 11CI'10 LENDING GENCY '
I Imrcby allinn Ih:n.there #onstr ion lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the prd;rtmance ole.Om ark f this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Cie C.l
Lender's Nam• n HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender i Addm.. ELECTRIC
I certily that I have read this application and stale Ihat the above VENTILATION FAN (SINGLE) #f X3.00
information is correct. I agree to comply with all city and county PLUMBING
•' ordinances aI state laws relating to building construction, and BOILER- (3 H.P.or 100,000 B.T.U.1 4.00
hereby oath'ed representatives ins inspection
this city es enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL �00
acreby n' ed pro rely for inspection purposes.
( •, i emnify d keep harmless the City of MISC.- REFER TO ORD
Cup in �a n Ii iliC s, udg a is,costs and expenses which CONST.TAX
Er
In n a n t City in conseq ense f the PERMIT ISSUANCE 3.
gran ng 'f s MECH.CONT. LIC.NO. MECH.
/ TOTAL 60 TOTAL
Signature o pplicant Contra t r al � ��
1I DDP . y