15678 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES USE BALL POINT PEN ONLY
•., t8U1t01 NG PROJECT IDENTIFICATIONPERMIT NUMBER
BUILDING ' APPLICATION & PERMIT 15678[ O
-7 ADDRESS I `J �J
Q Yf� �o BUILDING—ELECTRICAL—PLUMBING—MECHANICAL -�
NER /� - PLAN CHECK VALIDATION
"AME' QTY. ELECTRIC PERMIT FEE
a4,4,01e 114arloyHONE P
Na CRA
E croRs Q, UTLETS-SWITCHES-RECEP 10.00/1.00
LIC. O / LIGHTING FIXTURES 10.00/1.00 '
ronrRAcroas - PPLIANCES-RESIDENTIAL 4.00
AODREss
PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP):- 20:00 PLAN CH CK FEE P.C.NO.
OR
O
ENGINEER
' LIC NO SIGNS TRANS. 3.00 '
ADDRESS sloe. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
AS - MOTORS SEE FEE SCH. �.
ADDRESS
ADDR
SERVICE CHANGE 20.00
� a02 LICENSED CONTRACTORS DECLARATION COCA
¢ is u I hereby affirm that I am li¢nsed under provisions OTC I topic,9 ISSUANCE GATE -
ww (Commencing with Section 7000)Of Division 3 Of the Business and BLDG. ELECT. PLG. MECH.
Fri ' Professions Coale. rR6PI license ism tall lorw anh�eC
Z o'vf' - Littn ClassC�_•7 Lic.Number 4•E�J, El
Op �L,r Dole Contractor
— J
BUILDING PERMIT
¢A o OWNER-BUILDER DECLARATION
a MISC,— • REFER TO ORD INFORMATION
X ; LL I- -1 hereby affirm that 1 am compel from the Contacmr's License 'VALUATION S/FT.
F a_ 0< Law for the following reason.(Sec., s 7031.5.Basionand Profession PERMIT ISSUANCE 10.00
uu ,
Code Any city or cnly,which}cyuirusa are to mnslruct,alter,
re ¢ ¢Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.-
G u requires the applicant for such Permit to Cile a signed Statement that - TOTAL PERMIT TO
E
$ he is licensed pursuant to the provisions of the Contractors License D
R b ¢
Law(ChipmrY(cummcncing with S.¢tinn 70001 of Division3 of the - - •T L8
i O Business and Professions Code).or that he is exempt therefrom and. O PLUMBING PERMIT FEE '
¢ I- the basis for the alleged exemption.Any violation of5ection 7031.5 STORIES TYPE CONSTR.
n3 $ by any applicant for a permit subjects the applicant to a civil Penalty ALTER-DRAIN -WATER'IEA.) 5.00
of not more than five hundred dollars($500).): -
❑ Las owner at the will do the my employees with wages as BACK FLOW PROTECT. DEVICE 4.0 oee.GROUP v RES.UNITS
their sole compensation,will do the work.and the'structnm R not ,
- intended or offered for sale (See. 7044, Business and Prolessionz DRAINS-FLOOR,ROOF,AREA,CON
t Code:The Contractor's License Low does Rat apply to a I owner of -
Property who builds or improves themom,and who does such work FIXTURES-PERTRAP5.00 ea R.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended Oroffered for sale.If,however,the building GAS-EA,SYSTEM-1 INC.4 OUTLE
or improvement is sold within one year of completion,the owner. - GAS-EA.S .STEM-OV ER 4 (EA. 2.00
} budder will have the burden of proving that he did not build or ice- BUILDING USE
prove for purpose ofsaleJ. INDUSTRIALWASTEINTER. RES IND CON PB ' Odou
❑ •I,as owner of the pmperty,am exclusively Contracting with El •El El ' 13 1:1licensed contactors Io construct the project(file, 7044, Business LAWN SPRINKLERS-1 INC 5 Vi —6.00 ASSESSORSPARCELNO.
and Professions Code The Contractors License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00.
contacts.fur such projects with u contmctops)liccuwd pursuant to
the Contractor's License Law. r SEWER-SANITARY-STORM EA.200ft4lBr.M TRACT NO. PARCEL NO.
❑ lamcxempt under Sea :e.&P.C.forthls WATER HEATER W/VENT 6.00
reason
Owner ' Date WATER SYSTEM' 5.00 2 — Ace.DATE ace PILE No,
W'ORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 - -
Iherebyaffirm o rkehavericcosalme onamsent orxlfcuilwd ' ZONING ENG.SITE NO.
or a cthereof.(Sec.3600,Lab C)
712 PobCY. err Com Pant ni
�0 - ❑ Certili p he,CM1y(furnished. � _ � FIRE$PRINK ENERGY T-24
'Z Z Cert' y IsAled with Lily Rol x n division. MISC.- REFER TO ORD. ❑- ❑ ❑ ❑
O/, APPhcens `�('(� Y N V N
T PERMIT ISSUANCE --}9Q0 FLOoo ZONE A.L.uc.
LU CIi R'fI PICA COI PE SAI[ N ION PROh1 W'ORKIiRS' l�
- lL > t COMPENSATION INSd RA NCI: PLG.CONTR. U0.NO. PLG. q Y❑ N❑ Y ❑ N❑
� Z Lind
re section S10 not ss. completed if the permit is for one TOTAL oC
hundred dollars IS I OOl or less.) .
U O I certify that in the portonnatice of the work for which this per- QTY - MECHANICAL PERMIT FEE- FEE SUMMARY
1L F- mit is issued,I shall not employ-any peaon in any manner so as to
Qw become subject to the Workers'Compensation Laws of California. b. -
Hate -ApplicantD'AL,TER OR ADD TO MECH..s 5.00 BUILDING
} to NOTICE'r0 APPLICANT.. It,after making this Certificate of 1..
F Z emptioii,you should become subject to the Workers'Compensation APPLIANCE t ' 5.00 PLAN CHECK
provisions of the labor Cale, you must forthwith oc ly with FEE
U stmh provisions os this permit shall be deemed revoked:; AIR HANDLING UNIT(TO.10)000QF.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.NL) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) " 5.00 -
- 31le 097 CCiv.C.�nce of the work for which this Permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.)• 8.00 MICROFILM
Lender's Name
Lender's Address ,)9,50 HEATING UNIT ER 100,000 B.T.0ELECTRIC
I certify that I have read this application and state ohm the ahovu. VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county BOILER-CCYuP(3 H.P.or 100,000 B.T.U.1 6.00 PLUMBING
tied nd state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the IBOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned Pru Perry for inspection parpows- - _
a
ve, indemnify and keep harmless the City or MISC.- REFER TO.ORD.
abilities,judgmem costs and expenses which CONST.TAX
crue against ityin consequence of the PERMIT ISSUANCE 10.00
it., MECH.CONT. LIG NO. MECH. -
q TOTAL TOTAL
Signature of A pplwant/Con actor, este!
OFFICE COPY