9325 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LOI NG PROJECT 1 DENTI FI CATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
v ADDRESS G-ELECTRICAL-PLUMBING-MECHANICAL
79^ C
ONER'S PLAN CHECK VALIDATION
NAME A V ' Po f r )e J OTY. ELECTRIC PERMIT FEE
' PHONE
NAME TD UTLETS-SWITCHES-RECEP 10.00/1.00 CN
uc.Na' LIGHTING FIXTURES 10.00/1.00
ff �FFADDRESST Rs los 0'r-5 APPLIANCES-RESIDENTIAL 4.00
PHONEPANELS 10.00 DATE OF APPLICATION
ARCHTECT
OR
PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
AARCH OR DDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zlv TEMP.METER OR POLE INS. 20.00 `
nooasss Ts MOTORS 91 SEE FEE SCH.
92 clleg SERVICE CHANGE] 20.00 '
w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
c u W I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w < (commencing with'Seclion 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H w z Professions Code nd my license Is in full force and effect'
z o w - ])am License Class_ tic.Number ❑ ❑ ❑
o I7atd Contractors
z - M E ,
re a Ea' ' �r 0 BUILDING PERMIT
¢ �:w ¢ OWNER-BUILDER DtiCLA RATION INFORMATION
DaU MISC.- REFER TO ORD
.'reg u 1 hereby alfinn that I am exempt from the Conlructnrs License
leo ¢ Law For the lollowingreason.(Sec.7031.5,Business and vrol'essions PERMIT ISSUANCE nO rip t;VALUATION S/FT.
-' Code:Any city orcounly which requires a permit to construct,alter,
�"��
�Q r Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEG CONTR. LIG.NO. ELEC.
O ¢ requires the applicant for such permit to file a signed statement that _ TOTAL PER MIT TO
K
m he is licensed pursuant to the provisions of the Contractor's License
H z r Law(Chapter9(commencing with Section 7000)of Division 3 ofoa G
¢ Busbasis
and Professions Code)or that he is exempt therefrom and CITY PLUMBING PERMIT FEE
f Z
the bas for the alleged exemption.An}'vwlal fon of Section 703 LS STORIES TYPE CONSTR.
aim by any pplicart for a permit subjects the applicant Ina civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(S500).1:
❑ I;'s owner of the property.or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
tlmir so lerampensation,will do the work,and ore structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sea 7044„Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law docs not apply to an owner of
Property sell.builds or Improves Ibereon,and who does such work FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees provided that such improve- -EA.SYSTEM-11NC.40UTLETS 6.00
mu/ds are not intended or offered Por sale.ll',however,ore budding GAS
or Improvement is sold within one year of completion, - . .) 2.00 the owner- GAS EASYSTEM-OVER 4 (EABUILDING USE
builder will have the burden of proving that he did not build or im- -
prove for Purpose ofsale.). I" m
r INDUSTRIAL WASTE INTER30.00 RES IND CON PB Oer
0 1,a,owner of the properly,am exclusively contracting with . ❑ ❑ ❑ ❑ ❑
licensed c.atmemrs to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code: The 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'wilh a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
` the Contractors License Law. TRACT NO. PARCEL NO.
0 I am exempt under Sec. B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner ' Dare WATER SYSTEM 5.00
f( ACC.DATE ACC.FILE NO.
WORK ERS'COM PENSATION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm oral I have a certificate of consent In slLinrcure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
K copy Ihcrcol'(See 3800,Lab.C.I. /
Policy No. Company / ,Cb
O ❑ Cetlificd copy is hereby fu lshcti. " FIRESPRINK -ENERGYT24
Z }. Cert ificd upFr d the city inwpucl ion division. MISC.- REFER TO ORD.
p,\ p{�lslicanr-� 1� V ❑ N❑ V ❑ N❑
.r✓� N CERT IFICA'1'1:OF EXEMPTION FROM WORKERSPERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U,O.
IL > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
C Y❑ N❑ Y❑ N❑
0 ('Phis section need not be completed if the permit is for one TOTAL
D Z hundred dollar,(5100)or less.)
U O 1 certify that in the performance of the work for whichthis per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL H mit is issued. I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California. . BUILDING
y Date-Applicant ALTER OR ADD TO MECH. 5.00
} W NOTICE TO APPLICANT: If,after making this Certificate of En-
♦- Z empti.n,you should become subject to the 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=QF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MIC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for, EXHAUST HOOD(WITH DUCT) 5.00
the30• ,Cis.�anec of the work for which this permit is issuedMICROFILM
(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 '
Lender's Nano HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC
I certify that I have read this application and state that Ihcabove VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and county PLUMBING
ordinances and slut, laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000BTUISEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(W,) 'gree fo save, in keep harmless the City of misc.- REFER TO ORD.
Cope n ag inst liabilitieZgaisai
costs and expenses which PERMIT ISSUANCE 10.001CONST.TAX
D e n Bean ity in cons,qu,ncc of thegra ti i perm MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
1a
INSPECTOR COPY
I
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