18855 t intCJA1
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
B1JIL'DI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING ,_ APPLICATION & PERMIT 18855
ADDRESS
AA V AWE BUILDING-ELECTRICAL-PLUMBING-MECHANICAL i$i
OWNE�,RJ5' PLAN CHECK VALIDATION
so�.F,(/Jf 'tL //J�/./�.� CITY. ELECTRIC PERMIT FEE
S /T/u F'•N�/ NF
CONTRACTOR'S CAAo
NAME nL OUTLETS-SWITCHES-RECEP 10.00/1.00
�./ LIc.No.(�J�S LIGHTING FIXTURES 10.0011.00
CONTRACTORS AWAPPLIANCES-RESIDENTIAL 4.00
AWA / \/I �/� Q� cif L'
( m 1C SC-HONEW- 74 PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN C E P.C.NO.
OR PANELS (OVER 200 AMP) 20.00 ,
ENGINEER
LIC.No. SIGNS TRANS. 3.00 E
ADDDRESS ENO - SPECIALCIRCUIT - 5.00 VV111RY� - N
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH. 0-6
Ao RnEssC Waft
/'1-& 4 ao AM. SCrclQ SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DE CLARATION
¢ U U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
<G a w (commencing wilh Section 7000)of Division 3 of thG e Business and BLDELECT. PLO. MECH.or i 'ToCessiom C license is in full fo f
Z o m - License Class_ Lic.Number ❑ ❑ ❑
9 y w Date Conimctor
2
¢.y s - 'I BUILDING PERMIT
¢ ¢ w a OWNER-BUILDER ItECLA RATION rylW{v INFORMATION
andMISC.- REFER TO ORD
L. 1 hereby allium that I um excc.7 time the Contractor',andTro License - VALUATION S/FL
FLLL. Law for the following reason.(Sec.70}1.5,Btuinessdnd Profusions PERMIT ISSUANCE 10.00
Cod :Any city or county which requires a lxmlit to construct,alter,
G2 impr 'e,demolish.or repair any sHUcw RI.prior to its issuance,atm ELEC.CONTR. LIC.NO.
Li
require he applicant for such permit to file a signed statement that L PERMIT TO
w u, he is lice d purwam to the provisions of the Contractor's License
Fi> Law(Chap 9(cand mencingwith Section 7000)of Division 3Ofthe
a Business and rofesslons Code)or that he is exempt therefrom and OTV. PLUMBING PER Tis FEE
the basis for th allege)exemption.Any Salutation of Section 7031.5 STORIES TYPE CONSTR.
by anyapplican or a permit subjects the applicant toacivil penalty gLTER-DRAIN&VENT-WATER (EA.) '
of nor mom than 'e hundred dollars[55007.]:
❑ f,us owner o m property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole cam pensalio will do the work,and the slrveture is out
unlimited or offered for - (Sc,, 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 -
Code The Contractor's Li c Law docs not apply to an owner of
properly who bmld Contractor's
improv thc1con,and who docs Such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his
ow.f.. s.provided that Such improve GAS-
EA.SYSTEM-11NC.4 OUTLETS 6.00
mints are not intended or o(Cercd fo b.11:however,the building
or improvement is sold within one year completion,the owner. GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving th m did not build or int- BUILDING USE
prove for purpose of Sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON Pa Other
❑ 1,as owner of the property,Sun exclusive] - ntmcting with ❑ ❑ ❑ ❑ ❑
licensed contract,,, to F.Roi,et 0th pmiicet(sec. 4,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
unit Professions Codc:'I'he Contractor's License Lew doe of apply
In an owner of properly who builds or improves thereon. J who LAWN SPR IN KEEPS-OVER B (E,4) 1.00
Ucclthe Contractor's
onconsctor'shcense LwithaconlruemrlM licensed pars no SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Conv for such
License Law.
❑ lamexemptunder Sec ,B.&P.Cfonhis WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM - 5.00 ACC.GATE ,' ACC.FILE NO.
WORKERS'COMPFNSATION DECLARATION WATER TREATING EQUIP, 5.00
I hereby affirm thin l have a.ertificul,oI'Conscnt t,,self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or u cerlitied
copy there yyffr Se 00,Lab.C.). (r{/1-fL
I'ollcy No.��Cmup.ay O N'1�G rV/Vl�
Q ❑ etlili�yl copy is hemby(urnished. FIRE SPRINK ENERGY T-24
Cerri6A/.21d I file too division.
Z p Applicant lOF/77N �!'I - MISC.- REFER TO ORD. v ❑ N❑ v ❑ N❑
I--
X w PERMIT ISSUANCE 10.00 CERTIFICATE OF EXF-MPI'IPROM WORKERS' FLOOD ZONE A.L.u.c.
W > COMPENSATION INSURANCE
URANCIi PLG.CONTR. LIC,No. PLG.
CL 0( This section need not be completed if the permit is for one TOTAL YE] NE] Y ❑ NE]N
hundred do]Ia,1 S 100)or less.)
UO1 1 certify mpe
at in the rformance of rbc work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any mannrrso as to
U become subject to the Workers'Compensation Lawsof California.
u Date Applicant ALTER OR ADD TO MECH. 5.00 �x BUILDING
} m NOTICE TO APPLICANT: If,after musing this Certifcam of Iia- .
F 2eruption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
y. provisions of the Labor Code, you must forthwith comply with
CJ such provisions or this punnil shall be deemed revoked AIR HANDLING UNIT(TO 10=C.F.NL) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MCEM.) 6.00 SEISMIC FEE
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(Sea MICROFILM
3097.CeYC.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that I have real this application and slate that the abetc VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and 4Ounly PLUMBING
oFfrTsuees and stale laws relating to building construelion, dud BOILER-COMM H.P.or 100,000 B.T.U.) 6.00
hereby authorinc representatives of this city to enter upon the BOILER-COMP (Owe 100,000 BTO)SEE FEE SCH. MECHANICAL (�
above-mentioned property for inspcclion pur,ows.
(We) agree to save, indemnify and keep humorless the City of MISC.- REFER TO ORD.
ape lino g mustliabilities,j dgments, coats and expenses which CONST.TAX
ay in wax accere�t and Said City in consequence of the PERMIT ISSUANCE .'le-eB
nnti0 this plmi i, MECH.CONT. LIC.NO- s MECH.
✓ / TOTAL , TOTAL
ignature of Applican Contractor �U e /
OFFICE COPY
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