6786 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION PERMIT NUMBER v"
BUILDING APPLICATION & PERMIT
noon Ess r
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 678
E 'S 1 PLAN CHECK VALIDATION
"AME n QTY. ELECTRIC PERMIT FEE
(j PHONE
v NOMTERnCTOR OUTLETS-SWITCHES-RECEP 5.00/1.00 'f
LC.NO, LIGHTING FIXTURES 5.00/1.00
'OUT A r PPLIANCES-RESIDENTIAL 4.00
ADDR s
TONE PANELS 5.00 DATE OFF APPLICATION
ORRLRITECT SIGNS'i 6.00 PLAN CHUCK FEE P.C.NO.
ENGINEER
uc.No. SIGNS TRANS. 3.00
ADD ESS ENGSPECIAL CIRCUIT 5.00 PERMIT VALIDATION
IP EMP.METER OR POLE INS. 15.00
ADORIESsNT'S MOTORS SEE FEE SCH.
ADOREs
's SERVICE CHANGE 10.00
woo LICENSE CONTRACTORS DECLARATION
TO U 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w Q w (comnc
meing with Section 7000)of Division 3 of the Bessusinand BLDG. ELECT. PLG. MECH.
H m z Professions CoJ J 'ease is in full fore n f
z License Class Lie.Number
9 r w Date El I El LL
Contractor
¢ r s BUILDING PERMIT.
¢ m rw.¢ E -BUILDEiR OGCLARA I INFORMATION
A OAea MISC.- REFER TO ORD
Is g;LL r I hereby affirm that I am exempt from the Contractor's License VALUATION S/FT.
Huoa Law for the following reason.
(Sec 7031.5,Busin.rurd Professions PERMIT ISSUANCE 6.00
F m>E Code:Any city or county which reyuiresa permit to construct,alter, ELE4CONTR. LIC.NO.
2 ¢O improve,demolish,or repair any structure,prior to its issuance,also ELEC.
4 LL requires the applicant for such permit to Fite a signed statement that TOTAL PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractors License
Fzi Law,(Chapter 9(commencing with Section 7000)ofDivision 3 of the
B
¢ usness and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
a o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
dim by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
iniendcc or offend f r Ic (Sec. ]tM4, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor ase Law don not apply to an owner of
property who builds O 11 Ovn Ihemon,and who does such work F IXTUR ES-PER TRAP 4.00 SD.FT.FLUOR AREA TOTAL ACREAGE .
himxlf or Through rs mployms,provided that such improve-
• .cuts arc not int d ro Bred for sale.If,however,the building GAS-EA.SVSTEM-l 4.00
or improve. n s ithin one year of completion,the owner- GAS-EA.SYSTEM.OVER 4(EA.) 1.00 BUILDING USE
IT will have the hu en of proving that he did not build or im- RES IND CON PB Omer
prove I'or purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ 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. 5.00 ASSESSORS PARCEL NO.
and Profnssioms Code:1'he Contractor's License Law docs 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 o contractors)licensed pursuant to
the Contractor's Licerw Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. • ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
t WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent nr sell-inmre, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Incur ace,nr a certific
IF 0,Lab..C.)
ompany
O ❑ C ifed y she • y urnis ' FIRESPRINK ENERGY T 24
Z ZC tifie -tl City inspection division.
O App an _ r MISC.- REFER TO ORD. Y ❑ N Y ❑ N❑
Cr w CERTIFIC 'TE OF EXEMPTION FROM WORK CRS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
W > MPP.NSATION INSURANCE PLO.CONTE. I No, PLG.
6. ('This sect ion ed not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
Z) Z hundred dollars(5100)or last.)
U O 1 certify that in the performr Ce of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL 1- mit is issued,I shall not emplo an Acis u in any manner so as to
to t
U become subject he Workers' o p-as� ion Laws of Culifornin r
O to Dale App1t nt BUILDING i
a ALTER OR ADD TO MECH. 4.00 ,r
}.tn NOTICE TO AI'I'LICA If,a ter making this Certificate of lis
Z
eruption,you should bt sub em to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the or o ou must forthwith comply with FEE
U such provisions or this per it shal be deemed revoked AIR HANDLING UNIT(TO 10/100 QF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the perforin.Ce of the work br which this permit is issued(Sec. MICROFILM
3097,CN.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that a hi,. Icntionendstate that the above VENTILATION FAN (SINGLE) 3.00
.
IT is corregjyl a tr comply with all city and county PLUMBING
ordinances and state laws relati g to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.1 4.00
hereby ant prize representatives of this city to enter upon lire BOILER-COMP (Over 100,000 BTUISEE FEESCH. MECHANICAL
r
above-men ed property for inspection pugloses. y
(We to save indent'y an J keep harmless file City of MISC.- REFER TO ORD.
Cupe n t lint lilies,j meats, Costs and expenses which CONST.TAX
oy n a s said City in consequence of the PERMIT ISSUANCE 3.00
rant g I MECH,CONT. LIC.NO. MECH.
TOTAL TOTAL
Signatur o pplicanf of or Ualc ,*oleo
INSPECTOR COPY