18875 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LD ING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING _ APPLICATION & PERMIT O 0 717
Irl r1 BUILDING - ELECTRICAL-PLUMBING-MECHANICAL fa UO J
OW E 's 1 /� PLAN CHECK VALIDATION
"AM QTY. ELECTRIC PERMIT FEE
ROLA
co T ^crony 0 yl( /' r UTLETS-SWITCHES-REC 10. .00
I: "A l� `r y
---- - uc.uO. LIGHTING FIXTURES 0.02/
CONTRACTOR S. - PPLIANCES-RE91DE
AO RE55 . .
N PANEL$ Q. Q DATE OF-APPLICATION
ARCHITEC PANELS (OVER 200 MP 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.ND. SIGNS TRANS. 3.00
ADDRESS enc. SPECIAL CI 5,00 PERMIT VALIDATION
ZIP EMP.METEMR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE PXP, ' 20.00 \�
'oo
LICENSED CONTRACTORS UIiCLARATION J� "' -`� YIUG
rt v. I hereby affirm that 1 am liccnd under provisions of Chapter 9 S��� 170'0 ISSUANCE DATE
« z w
(commencing with Section 7100)of Division 3 of the Business and BLDG. ELECT. PLG. WECH.
r y i Professions Coh,a- license is in lull to EJ e
- z i m O Licenscass� Lic.Nulnbcr `vl(y Q 1,1109(1 ❑ ❑
O Dute_ Cnnl mclor ✓-5_
k BUILDING PERMIT
wOWNBR-BUILDER DECLARATION INFORMATION
F
3 ¢ H I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION S/FT.
Fuo� Law for the following reason.(Sec.703 1,5.Business and Professions PERMIT ISSUANCE 10.00
yam+ Cale:Any city orcounty which requiresx permit toconstruct.alter.
R ¢Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
G a- requires ne applicant for such permit to ole a signed statement that
nse TOTAL P
w re ui licensed pursuant to the provisions of the signed
Contractor's Limns(
Hzi
Law Chapter 9[commencing with Seeeion 7000)of Division Sof the
a Basin,.and 1'rfatsions Codcl or Bull It,is exempt therefrom and QTY. PLUMBING PERMIT FEE
ce the basis for the alleged exemption.Any violation ofSection 7031.5 St
DRIES TYPE CONSTR.
n ; - by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than fee hundred dollars(S5001.1:
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 4.00 DEC.GROUP RES.UNITS
f their sole compensation,will do the work,and the structure B not
intended or offered for sale (Sec. 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 who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 Sa FT FLOOR AREA TOTALACREACE
himself re through his own employees,pe.It,however,leve such offered for lu.lf,ed thatthe hulloing GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,lire owner- GAS-EASYSTEM-OVER 4(EA.) 200 BUILDING USE
builder will have the burden of proving that he did not build or I.,- . . .
- RES IND CON PB Omer
prove 1,aso nee of sale.p INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
❑ d as owner of the construct
he exclusively contracting with
• licensed contractors : ce C,NDu the project(Sea 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Cale:The horrruclor's License low dots not apply
to
-
eo contracts
owner of h projects
s with a lits tr improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
the coc(s¢mrsoch projects with u uvmcmrtsl licensed pursuant m -
theContrucmr'sLieenseLaw.- SEWER-SANITARY-STORM EA.200ft/10.00 TRACT No. PARCEL NO.
❑ I am exempt under Sec ,B.&PC.for this WATER HEATER W/VENT
reaSml
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
W'ORKERS'CO,MPENSATION D17CLARATION WATER TREATING EQUIP. 8.00
I hereby attire that I have a cartieicaee of consent to wif insure, ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(See 3800,Lab C.).
Policy No. Company -
❑ Certit ied copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division.
O Applicant MISC.- REFER TO ORD. Y ❑ N v ❑ No
N CERI'IFICA1 E OF EXEMPT[ON PROM WORKERS' PERMIT ISSUANCE FLOOD ZONE A.L.U.c.
IL > COMPENSATION INSURANCE. PLG.CONTR. LIC.NO. PLO. ,y-1 Y El N❑ Y 1:1N 11(This section need nut be conlDletcd if the permit is lnc
for nine - TOTAL lir/
hundred dollars IS 1 W)or less.)
U O 1 certify (fiat in the performance of the work for which this Per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued, I shall not employ any persue in any manner so as to
U tecome subject tothe Workers'Compensation Laws of California.
C. Datc Appliant ALTER OR ADD TO MECH. '5.00 'BUILDING
} 0 NOTICE TO APPLICANT: If,after making this Certificate of Its-
2 emption,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=C.F.NL) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=CF.M.) 6.00 SEISMIC FEE .
1 hereby affirm that there is unstructiun lendtns agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(See. MICROFILM
3097,Civ.C.), HEATING UNIT(TO 100,000 B.T.U:) .8.00
_ Lenders Name
Lender's NameAddress
NHEATING UNIT(OVER 100,000 B.T.U.0.50 ELECTRIC
I certify that I have read this application and state that the above
VENTILATION LATION FAN (SINGLE) 4.00
information r correct 1 agree 1i comply with all city and countyER-ODtvP(3 H.P.or 1(x1,000 B.T.U.) 6.00PLUMBING
sodininfor atio and orrec Ivws reeM.1in,c m building contruction, andherebyamhorses representatives of ten city (o en to ulxm sheLER-COMP (Over 1W,000 BTU)SEE FEE SCH. MECHANICAL
almvc-mentioned properY for inspection par,o s.(We) agree In save. indemnify unit keep harmless lire City ofC.- REFER TO ORD.
- uperino against liabilities,judgments, costs end expenses which CONST.TAX
may in any way accrue against mid City in consequence of the PERMIT ISSUANCE 10.00
n . gazof this pernil. MECH. ONE. LIC.NO. - MECH.
-7D TOTAL TOTAL
lidittepstilfrWApplicafft/CIanttr Date
OFFICE COPY