6740 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I ENTI FICATION APPLICATION Sl PERMIT PERMIT NUMBER -
BU
UDLNG
IUI55 DUM
BUILDINGELECTRICAL—C 0
OwRE.S PLAN CHECK VALIDATION
NAME
- OTY. ELECTRIC PERMIT FEE
C�R3s�x�HGrvE
COMERNCTOR5 s UTLETS-SWITCHES-RECEP 5.00/1.00
LICNO. LIGHTING FIXTURES 5.00/1.00
I 2k
coNTRACTOR' u/�� PPLIANCES-RESIDENTIAL 4.00
ADDRESS 4:2-
J� /
L(i /� PHON 6`0$ PANELS. 5.00 DATE OF APPLICATION
..cioilnr SIGNS I 6p0 PLANCHECK FEE ' P.C.NO.
OR .
ENGINEER
LIc,No. SIGNS TRANS. 3.00
ADDRESSOR ENG. SPECIAL CIRCUIT '5,00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 15.00
ADD MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00S�//, /7
O00 LICENSED CONfRACfORS DECLARATION I•' 1QQd
rc as
Quo I hereby affirm that I am IicenscJ under provision of Chapter 9 ISSUANCE DATE
¢a (eommencing RLDG
with Section 7000)of-Division 3 of the Business and . ELECT. PLG. MECH.
rD i Professions C an my license is in full force and effect. Ih Nino i _
z D v� — Licenx Lia Number ❑ ❑ ❑ ❑
ss
2 Z H w Dulc� Contractor '
a Y s BUILDING PERMIT
is c w ¢ OWNER-BUILDER DECLARA'rlCN - INF N
REFER TO ORD
•w 3 A n I hereby affirm that I am exempt from the Contractor License MISQ— VALUATION $/FT.
H u o at Law for the following reason.(Sec.7031.5,Businessand Profesiluns PERMIT ISSUANCE 6,00
N;�
Code:Any City,ur countywhich res equira pinuil to construct,
IS a, Q improve,demolish,or repair any structure,prior to its issuance,also TOTAL ELEC.CONTR." LIC,NO.. ELEC. / / 1� Q A
0 LL PLNuiRS the applicant for such permit to file a signed statement that .� PERMIT TO "v
whe u licensed pursuant to the proviuons of the Contractor's License
H i Q Law(Chapter 9 Commencing with Section 7000)of Division 3 ofthe
1 4 o Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
IS H _the basis for the alleged exemption.Any violaton of Section 7031.5 STORIES STR.
by any applicant fur u permit subjects the applicant IouCivil penalty ALTER-DRAIN&VENT-WATER IEA.) 4.00
of not more than five hundred dollum($500)J:
❑ h as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sae (Sec, 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves themon,and who does such work FIXT_UR ES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,Provided that such improve-
Trendsarenot intended oroffered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4,00
or Improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or int- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB Omer
❑ I,as owner of the property,am exclusively contracting with' ❑ ❑ 1:1. ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC'5 V.B. 5.00 ASSESSORS PARCEL NO.
and Profession Coda:The Contractor's License Law does not apply
to an owner of properly who builds or improves t hereon.and who LAWN SPRINKLERS-OVER 5 (EA.) •1,00
contracts for such projects with a contractor(:)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec.—,ILAP.C.for this WATER HEATER W/VENT 4,00
mason
owner Du[c WATER SYSTEM 4.00 ACC.DATE ACC,FILE NO.
WO RKERS'COMPENSAT ION DECLARATION' WATER TREATING EQUIP. 4.00
I hereby affirm that 1 have a eertificxle ore.nuot to sett-inntra
or a certificate of Workers Compensation Insurance,or a certified ZONING ENG.SITE N0.
V copy dhcrcofl Sec..1B00,fab.0 - �Z /Sa�
Policy cru Cmmpa -
Q ❑ Ccrlilied copy is heaby urouhcd. FIRE SPRINK ENERGY Tia
z Z ❑ Certi d y ' h nspeCiion division. -
AppliCan —�J.S7C1C MISC.- REFER TO ORD. Y❑ No Y ❑ N❑
cc: T CFRTI FICA'If:OF EXEMPT[ON F ROMWOR KERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.UC.
W > COMPENSATION INSURANCE I PLG.CONTR. - LIC.NO; PLG. ❑ N❑ Y ❑ N❑
� Z ('Phis section reed nut be completed if the permit is for one - TOTAL
hundred dollars(S I OO)or Ii
U O 1 certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
W 1— mid is issued,I shall not employ any person in any minner so as to
U bee"me subject to the Workers msa
Copention Laws uFCaliforu. 4.00 po
Q to Data Ah licant
ALTER OR ADD TO ME BUILDING O sf a
a l p - F+
} W NOTICE TO APPLICANT: If,after making this Certificate of 1!x.
2 emption,you should become subject to the Workers Compensation APPLIANCE 4.00 PLAN CHECK
prosisior of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TQ
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.6M) 5.00 SEISMIC FEE -
I hereby affirm that then: is a Construction lending agency to, EXHAUST HOOD(WITHIDUCLIlpB ,00
the performance of the work for which this permit is issued](Sec. MICROFILM
3197.Civ.C.I �'0.y1 ��'i�apN.Q[I� HEATING UNIT(TO 100,000 B:T.U.) •4.00
Lender's Name HEATING UNIT(OVER 100,000B.T.U.)7.50
Lender's Name �' ELECTRIC
1 certify that I have read this application and stake that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all City and county PLUMBING
ordinina 'nd state laws relating to building construction, and BOILER-CONP(3H.P.on100,000B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP IOser100,000BTUISEE FEESCH. MECHANICAL �g
above mentioned property for inspection purposes.
(We) agree t save, indemnify and keep harmless the City of misc.- REFER TO ORD.
Cupenim again liabilities,judganents, costs and expenses which CONST.TAX .h
PERMIT ISSUANCE 3.00
may in, y w accrue against said City in consequence of the
h th permit. MECH.CONT. LIC.NO. ^ '• MECH.
TOTAL p/ TOTAL /< 9
f 1 pP nl ontmcto Date
OFFICE COPY '