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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
. BUI LDI NG PROJECT I DENTI FICATION
APPLICATION &PERMIT
PERMIT NUMBER ,
17367
BUILDING
ADoq Ess
,1 �./_
v T
BUILDING -ELECTRICAL -PLUMBING -MECHANICAL
0
OWNE 's
PLAN CHECK VALIDATION
"A •� �.
QTY. ELECTRIC PERMIT FEE
DATE OF APPLICATION.
CONTRACTORS
NAM _
/ SLic. No.
UTLETS-SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES- -10,00/1.00
CONTRACTOR
��y PMON �D- 666
PPLIANCES- RESIDENTIAL -4.00
PANELS 10.00
ARCHITECT
oR
ENGINEER
- LOC. No.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
,
'
SIGNS TRANS. 3.00
ARCH. OR ENG.
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
ZIP
` -,� v. [0
l �).r6d. (,
r
3 -aA-_!-1 -
ADDRESS rs -
ADDRESS
MOTORS SEE FEE SCH,
SERVICECHANGE 20.00
AND
LICGNSIiU COMBACI ORS DECLARATION
-
-IN 7
I herebyaffirm that I am licensed under provisions ob Chapter 9
ISSUANCE DATE
(commencing w'th Section 7000) of Division 3 of the Business and
Professions C �, a n 'cense is in full f LC�gd. ify 1.rtor
License Class Lie. Numhey-�JrX I/J��
Date Contractor
BLDG.
ELECT.
El
PLG. M CH.
CX ILNL
/a, -
ly of r"11909
ING PERMIT
BUILDINFORMATION
OWNER -BUILDER DECLARATION
I hereby Poll 11 that 1 Ym exempt front .5 t u Contractor'sLicense
Law for the following reason. (Sec. Business onJ Professions
INFORMATION
C" .REFER TO ORD
VALUATION 5/FT.
T $U CE 10.00
uiresa.
Code: Any city or county which ssquirCsa permit m construct, I
improve, demolish, or repair any xvucturc, prior to its issuunco, alsa
-
ELEC. CONTR. O LIC. N0.
ELEG
requires the applicant for such pemtit to Tic $signed slatement that
he is licensed pursuant to the provisions of the Contractor's License
TOTAL
PERMIT TO
L
CITY. PLUMBING PERMIT FEE
Law (Chapter 9(commencing with Section 7000) of Division 3 of the
Business and professions Code) or that he is exempt therefrom and
�% H
the basis for the alleged exemption. Any violation of Section 7031.5
ST RIES TYP O
by any applicant for a permit subjects the applicant boa civil penalty
effort more than five hundred dollars 155001.1:
'
ALTER -DRAIN & VENT -WATER (EA.) 5.00
C 1, as owner of the property, ar my employees with wages as
their Vile compensation, will do the work, and the Itnurture 6 not
BACKFLOW PROTECT. DEVICE 4.00 Q
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00 •'
190-
intended or offered for Sale (Sec. 7044, Business and Professions
Code: 'fhc Contractor's License law does not apply to an owner Ad
property who builds or improves thereon, and who docs such work
FIXTURES -PER TRAP 5.0
so. Fr. FLDOR AREA
-TOTAL ACREAGE
himself or through his own employees, provided that such iniprovo-
ments am not intended or offered for sale. I C however, the building
' GAS - EA. SYSTEM -1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or int-
prove for pllrPOW of sak.).
❑ L as owner of the properly, am exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
USE
RES IND BUILDING INGCON PB Omar
El El El El 1:3
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
licensed contractors to Consumer the project (Sec. 7044, Business
and Professions Code: The Contractor's License Low does not apply
to an owner of properly who builds or improves thereon, and who
contracts for such projects with a contractoost licensed pursuant to
the Contractor's License law.
SEWER -SANITARY -STORM EA. 200ft/10.00 O
TRACT NO.
PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C. for this
realm
WATER HEATER W/VENT 6.00 e2 P
Owner DHe
WATER SYSTEM 5.00 a
ACC. DATE
ACG FILE NO.
WATER TREATING EQUIP. 5.00
WORK ERS'CONPENSA'fION DECLARATION
I hereby affirm that I have o certificate of conunt lo. 1ftnsura
Compention hnSZcea, or,rtiled
or a certificate it Worker,'sa
- -
ZONING
ENG. SITE NO.
.
copy the o 9g b.C.).
Policy any
Cl ,crti le ul 'r'y(uro' J.
Qp' Cetlit7 is witl he city inspection division.
pplicant
FIRE SPRINK
Y � IN
ENERGY T 24
Y [:] NC]
MISC. - REFER TO ORD.
CERTIFICATE OF EX1iMPT1ON FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U.C.
PLG.CONTR, LIC. NO.
-
PLG. �OG
TOTA
COMPENSATION NSIIRANCE
section deed not be completed if the permit is for ane
V� N�
Y� NE]
hundred dollars IS 100) or less I
I mr1Ty that 'm the lerfoona 1c of the work for which this ler-
mit is issued, I shall not employ any person in any Inanner so as to
CITY MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers' Compensation Laws of California.
Date Applicant
NOTICE TO AI'PLICAN'I': If, after making this Cerlificate of Ex-
ALTER OR ADD TO MECH. 5.00
APPLIANCE 1 5.00
PLAN CHECK
emption, you slmuld become subject ra the ubrkers'Compensatiun
provisions of the Labor Code, you most forthwith comply with
such provisions or this permit shat[ be deemed revoked.
FEE
AIR HANDLING UNIT (TO IO)0ODCF.M.) 4.00
AIR HANDLING UNIT (OV ER l0,00DC.EM.I 6.00 O"o
SEISMIC FEE
CONS 'I'RUCI'ION LENDING ACIiNCY
I hereby' affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.). ��'
ALaA
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
Lender's Nam4U2A6-1- hr fr/.
Lender i Addmss
I certify that I have read this application and state that the aboveD
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction. and
VENTILATION FAN (SINGLE) 4.00 a
PLUMBING
b�b
BOILER -COAT (3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH S�
MECHANICAL
167
hereby authorize repres ntatives of this City to enter upon the
above property for inspection p
rmurposes.
MISC. - REFER TO ORD.
(We) agree to save, indenmify and keep Iwrmlass the City or
judgments, costs and expenses which
ainst said City in consequence of the
TAX
PERMIT ISSUANCE 1000+�CONST.
M&K�
MECH. CONT. - LIC. NO.
MECH.
TorAL
DD
TOTAL
7
Igneture of Applicant/Contmcmr Date
I
OFFICE COPY