C9416 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 8416
A R
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER' PLAN CHECK VALIDATION
nme QTY. ELECTRIC PERMIT FEE
ORHONE
NDAMFRAcioR's OUTLETS-SWITCHES-RECEP 10.00/1.00
uc, LIGHTING FIXTURES 10.00/1.00 "J
r. URESSTOR PPLIANCES-RESIDENTIAL 4.00
P_1- PANELS 10.00 DATE OF APPLICATION
LHITECi PANELS 200 AMP) 20.00 PLAN CHECK FEE P,0.NO,
OR
ENGINEER
LIgAO, SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5,00 ` PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLICANT'S MOTORS ' SEE FEE SCH. =//y
ADDRE55 J� 1
SERVICE CHANGE 20.00
'02 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a v U I hereby affirm that I am licensed under provisions at Chapter 9 ISSUANCE DATE
wa w (commencing with Section 7000)of Division 3 0(the Business and SL ELECT. PLG. MECH.
F N z Professionsa ul my license is io full force and effect. ( El 1-1 ❑
2 o m - License Clas Lic.Number
o m F0. .,are Contract
¢ m s BUILDING PERMIT
a as OWNFi R-BUILDER UECLARA'rION
d o a ea MISC.- d REFER TO ORD INFORMATION
X LL H I herby affirm ing I mn exmc.7 from the inessactar's License
u_Oa Law for the following reason l5,c.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city orcounty which requiresa permit to construct,alter,
¢ s- 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. 'AN^/
O a requires the applicant for such permit to file a signed statement that TOTAL ,I PERMIT TO
K
m LL he is licensed pursuant to the provisions of the Contractor's License
r z r
Law(Chapter 9(commencing with Section 7000)o(Uivision3of the w /CPQ/U�
¢ Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
f i o
a I- the basis for the alleged exemption.Any applicant tSection malty STORIES TYPE CONSTR.
d ; _ by any ore applicant fora permit subjects the applicant toacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
or not more than five hundred dollars(5500).): x
❑ I,as owner m'the property,or my employees with wages as BACK F LOW PROTECT. DEV ICE 4.00 OCC.GROUP RES.UNITS /
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself re through his own employees,provided eve such ibuildi a f
mmnc are not through his or offered for nemployeesulroided that suhe...pro ng GAS•=EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- , GAS EA.SYSTEM-OVER 4-(EA.) 200
builder will have the burden of proving that b -e did not build or in, . BUILDING USE y
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PS Other
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ _/ ❑
licensed contractors to construct the project (Sec.7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
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 e
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 r
the Contractors License Law. TRACT NO. PARCEL NO.
O.Iam exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00 11
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSA'rION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I hove a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
�op�ppyp�thppee�', ISec 3 Lab.
U Pdtl`4{FF. ntl n _
1 Copy'is er. yf rniited. FIRE SPRINK ENERGY.T 24
Z Z ' ❑ Certifiyit copy 's filed with the city inspection division. MISC.- REF ER TO OR D.
O Apphcam Y ❑ N❑ v ❑ N❑
~ w PERMIT ISSUANCE 10.00
Lu CIiRTII%CCOEPEN ATIO rINSURAN WORKERS' FLOOD ZONE A.L.0 c.
W COMPENSATION INSURANCE PLG.CONTR. LIC.No. PLG.
d v❑ N❑ V❑ N❑
O (This section need not be completal if the permit is for one TOTAL
U O h°1 decd dollars 1 n lite Larpe fort
1 certify that h the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
ILL0U mit is issued,e I shall not employ any person in any msmt,rml C to
O W become Cu object m`ihe Workers Compensation Lvws of Culil'ornia.
o. Data I Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT': If,atter making this Certificate of Ex-
f- Z emption,YOU should become subject to the Workers'Compensation APPLIANCE v 5.00PLAN 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 10000C.F.M.) 4,00
CONS'FRUCCION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
lite Performance of the work for which this permit is issued(Sec. MICROFI LM
3097,Cie G.). �� � HEATING UNIT(TO 100,000 B.T.U.) 8.00 I
Lender's Name HEATING UNITIOVER 100,000 B.T.U.)9.50
Lender's Address -�� ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby au ratio, representatives of this city to cater upon the •.r
1 above-men otied property for inspection purposes. BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
yI 6in
a to sm,v, indemnify'and keep harmless the City of MISC.- REFER TO ORD.
ainst liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX -
way accrue against said Cityin cons,qu,nce of the
is per(il� CH.CONT. LIC NO. MECH1TOTAL - TOTAL
Signalurcol 'pp' rU Contract r Ualc �•
INSPECTOR COPY '