16746 ItPPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
N .
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER '
31RVILDING APPLICATION & PERMIT
ADDRESS BUILDING ELECTRICAL-PLUMBING-MECHANICAL 16746 o 4 Zr/
OWNER'S PLAN CHECK VALIDATION
Nt{'I-i TY. ELECTRIC PERMIT FEE
P„ONE /7
CONTRACTOR'S UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
,ADDRESS RACTOR's
�(/ ' Y`5 LIC.NO. LIGHTING FIXTURES 10.00/1.00 '
fDAPPLIANCES-RESIDENTIAL 4.00
�C ONE PANELS 10.00 DATE OF APPLICATION i
A RITECT PLAN CHECK FEE P.C:NO.
onPANELS (OVER 200 AMP) 20.00
ENGINEER
t LIC.No. SIGNS TRANS. 3.00
AARCH. RDDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
EMP.METER OR POLE INS. 20"00 _
P ¢A 's MOTORS SEE FEE SCH.
ASSREss
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION '
¢ v I I Imreby affirm that I ren licensed under provisions of Chapter 9 ss) ISSUANCE DATE
mz w (commencing with Section 7000)of Division 3 of Me Business and
¢ a I 1 B ELECT. PLG. MECH.
H m i rofessions Code,and mY license is in full force m feel. V ❑
Z 0 w.o Licenser Lic Numbe ���� 0 ❑
o H Dale Contractor.
a y s / - BUILDING PERMIT
¢ ¢ w a OWNER-BUILDER DEC ION -
o a o MISC.- REFER TO ORD INFORMATION
w3 LL y 1 hereby affirm that 1 am exempt from the Contraclnr s License VA LUATIGN 5/FT.
FUOa Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE -49;08ZT
Code:Any city or county which requires a permit to most rust,alter,
reQ ¢ M improve.demolish,or repair any structure poor t0 Its Issuance,also ELEC.CONTR. LIC:NO- ELEC
O ¢ requires the applicant for such Pemlit to flea signed stalement that ,. TOTAL _ PEpRMIT TO
n.w he la licensed pursuant to the provisions of the Contractor's 3 License ��X4 N �7
r
Law(Chapter ndprcosions Cngwith Section is 010)exempt
D theren3 and /
M i o Badness and he alleged
Codec or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE.
¢ r the basisfor theah legedexemption.Any violation ppct to a cion malty _" STORIES TYPE CONSTR.
w. by any applicant tbra hundred coffins
tire applicant tuanvilpenally ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundruJ Jollun($500).):
❑ h as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE ' 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is out
_ intended Or offered for sale(Sea 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 improves thereon.and who docs wen work FIXTURES-PER TRAP 5.00 Sa FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employers,provided that such improve-
ments are not intended or otfered for We.If,however,The building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
piorefor purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Octel
/❑ Las owner of the property,am exclusively contracting wilh ❑ - ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL rv0.
and Professions Code:The Contractor's License Law does 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 with a contructorls)licensed pursuant to SEWER-SAN V-STORM EA.200ft110.00
_ the Contractor,License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner . Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS I COMPENSAT ION DECLARATION WATER TREATING EQUIP., 5.00
1 hereby affirm that I have a certificate of consent to self-inwmZONING ENG.SITE N0.
or a cert ificme of Workers'Compcn atiun Insurance,or u certified
1 copy lhcreuf(Sec.3800,Lab.C.l.
Policy No. C to a,'
O ❑ Certified cop heRby furnilud. / FIRE SPRINK ENERGY T 24
Z 2 ❑ Ce m py is file with th• u n div' MISC.- REFER TO ORD.
nPPlicunl Y ❑ N❑ V ❑ N❑
ern CERTIFICATE 017 E:a_MpIION I'RO RAIiRS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.c.
W > COMPENSATION INSURANCE, PLG.CONTR., LIC.NO. PLG. - v❑ N❑ Y❑ N❑
� Z (This section need not be completed if the permit is for one TOTAL
hundred dollars IS 100)or Icss I
U O I certify that In the performance of the work for which this per- CITY MECHANICAL PERMIT FEE FEE SUMMARY
ly 1- fest is issued.I hall not employ any person in any manner so as to
Ow hecolne subject w the Workers'Compenmt ion Laws of Celifondx. BUILDING
O_ Uatc Applicant - ALTER OR ADD TO MECH. 5.00
} m NOTICE TO APPLICANT: If,after making this Certificate of Ex.
F. nnption,you should become subXct to the Workers'CompemAtion APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you n usI forthwith comply with FEE
U such provisions or this pennit shall be devoted revoked. AIR HANDLING UNIT(TO 10,0MCRIA) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affiml 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. MICROFILM
3097,G,C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lenders Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
..
I;certity that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is mrrect.1 agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building tenstruclion, and BOILER-CCYvP(3 H.P.or 100,000 B.T.U.) 6.00
hereby autloriru representatives of RE, city Gr enter upon the BOILER-COMP (Over lOD,0008TU15EE FEE SCH. MECHANICAL
4as
ea p operty for inspection purposes.
ve, indemnify and keets armless the City f MISC.- REFER TO ORD.
-f sl liabilities,judymlews, and exnses II PERMIT ISSUANCE 10.00 CONST.TAX
ay accrue against scyucn' the
s penniLMECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
pplicant/ ontractor z Date
OFFICE COPY