9107 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT 9107
� o l
BULDIN
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNED S_5y,r✓��C• ,IE Ree CK.•� OFF/GF PLAN CHECK VALIDATION
NAME <J/ .J QTY. ELECTRIC PERMIT FEE
i
17ONE
Tc✓L ac
S
. Ante AcraRsUTLETS-SWITCHES-RECEP 10.00/1.00
uc.NO. LIGHTING FIXTURES 10.00/1.00 N '
ADDRESS oHs PPLIANCES-RESIDENTIAL 4.00
CONTRA
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
O
ENGINEER
uc,No. SIGNS TRANS. 3.00
ADDFESS ON ENG' SPECIAL CIRCUIT 5.00 - PERMIT VALIDATION
zap TEMP.METER OR POLE INS. 20.00
ASMOTORS SEE FEE SCH.
I
ADDRESS
SERVICE CHANGE 20.000 ac I L
i
` o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
r vu Thereby affirm that I am licensed under Provisions of Chapter 9 ISSUANCE DATE
*' y Q WA. (commencing with Section 7000)of Division 3 of Ilse Business and BLDG. ELECT. PLG. MECH.
H w zAProfessions Code,and my license is in full force and effect. ❑ ❑ ❑
z 0,.� - License Class L ic.Number
:0 ,Area Date Contractor
a Y f BUILDING PERMIT
re M ¢ OWNER-BUILLER DECLARATION
o a ° MISC.- REFER TO ORD INFORMATION
' w g LL 1 hereby affirm that I am exempt from the Contractor's License
j ri. VALUATION $/FT.
F a_ o j Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE -ULM (/y
m � Code:Any city or county which requires a permit to construct,alter,
'tom ¢ ¢ 0 improve, demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. ,
I_uaD ¢ requires the applicant for such permit to IIIc a Signed Statement that TOTAL
Ir w se" he is licensed pursuant to the provisions of tPER T TOhe Contractor's License n /
i
Law(Chapter 9(Commencing with Section 7000)of Division 3 of the d(
io. Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
I. ¢ H the basis for the alleged exenquim,Any violation ul Section 7031.5 STORIES TYPE CONSTR
j' as , by anyapplicunl forupermil subjects the applicant toa civil penalty
ll ofnot more than five hundred dollars(55001.): 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 compensation,will do(he work,and the structure is not
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or imprrves III aeon,and who does such work F IXTUR ES-PER TRAP 5.00 So.FT.FLOOR AREA TOTAL ACREAGE
�.i himself or through his own enhployces,provided that such improvo- /
GAS-EA.SVSTEM-1 6.00
merits are not intended or offered for sale.If,however,the building i
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 1EA.1 2.00 ED
G USE
builder will have the burden of proving that he did not build or int- RES IND N PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
.s� 1,as owner of the property,am exclusively contracting with ElEl YJ❑ ❑
tic used contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 WC 5 V.B. 6.00 ASSESS7 PA CEL No.
and Professions Code:The Contmclor's License Low does not apply
air n owner it property who builds or improves Ih,mor.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 ,
contracts for such projects with it contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200f1/10.00
the Con Im'lur',License Law. TRACT NO, PARCEL NO.
❑ I' h •xempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
\ Owne Date WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO.
'O KISRS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
I iemby affirm that I hove a certificate of,onsent to self-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof ISce.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE BPRINK ENERGY T 2
_Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
Q Applicant V❑ N❑ Y ❑ N❑
~ vaPERMIT ISSUANCE 10.00
CIiRT11rICATE CAEION IFROM WORKERS' FLOOo ZONE A.L.U.C.
• W � COh1PENSAI'ION INSURANCE PLG.CONTR. LIC.NO. PLG.
d a (This section need not be completed if the permit is for one TOTAL Y❑ N Y ❑ IN
•D Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
iia Dmc Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} 0 NOTICE '10 APPLICANT: H.atter making this Certificate of E.-
Z_ eiription,you should become subject to tire Workers Compensation APPLIANCE 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 S2 SZ
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the perlornanc, of the work for which this permit is issued(Sec. MICROFILM
3097,Cie C.). HEATING UNIT (TO 100,000 B.T.U.) 8.00 G
Lenders Nume
Lender's Addre / '� HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC �
��
I certify that 1 have read Lhis application and state(hal the above VENTILATION FAN (SINGLE) 4.00
®. information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-OOMPI3 H.P.or 100,0008.T.U.) 6.00 x
hereby authorize representatives of this city to enter upon tire BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above mentioned property for inspection purposes.
(We) agree to save, indemnify and keep brimless the City of MISC.- REFER TO ORD.
Caped' against liabilities,judgments, costs and expenses which CONST.TAX
may/in by way accrue against said City in cunseyuence of the PERMIT ISSUANCE 10.00 •`
t. gr lin f iii permit. MECH.CONT. LIC.NO. MECH.
� TOTAL TOTAL
-1 C-1
/ g hR Apphcamt/ onlbruchm
INSPECTOR COPY