8364 APPLICANT TO FILL IN,INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
J
ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL8364
'S PLAN CHECK VALIDATION
NAME- QTY. ELECTRIC PERMIT FEE
PHONE
t • NOME ACTOR UTLETS-SWITCHES-RECEP 10.00/1.00
f 7` _ Llc LIGHTING FIXTURES 10,00/1.00
TIONPORINCTOR �s APPLIANCES-RESIDENTIAL 4.00
ADDRESS I 6
DN� PANELS 10,00 DATE OF APPLICATION
APORITECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
I sec.No. r SIGNS TRANS. 3.00
NRCH.OR ADDRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
ADDREPPLICSS MOTORS SEE FEE SCH.
ADUREs (-
SERVICE CHANGE 20.00
woo LICIINSI!D CONTRACTORS DECLARATION TEMP.POLE 30.00
¢ L,u I hereby affirm that I umJicensed under provisions of Chapter 9 ISSUANCE DATE
a 2 w (commencing with Section 7000)of Division 3 of the Business and
a H BLDG. ELECT. PLC. MECH.
D a Professions Code,and my license is in full force and effect. ❑ ❑
z O m - License Lic.Number
Q m H w Date Contract
ams 1BUILDING PERMIT
¢ ¢ OWNER-BUILDER DECLARATION
a o a O INFORMATION
se ; LL H I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
, 0 < Law for the following reason,11ce,7031.5.Idusinessand Professions PERMIT ISSUANCE 10.00 vALunnON 8/RT.
F Code:Any city orcounty which reyuiusa permitloconslruct,alter,
2 a Q �' improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O o requires the applicant for such permit to file a signed Statement that TOTAL PERMIT TO
d w m he is licensed pursuant to the provisions of life Contractor's License
r z¢ Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
i D Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ f m the basis for the alleged esemplion.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ; _ by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(55001.):
❑ I,as owner of the properly,or my cnlPloyces with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure Is not
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 does such work FIXTURES-PER TRAP 5.00 SD.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve. .
mcuts are not intended or Offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC-40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or im BUILDING USE
RES IND CON PB Other
prose 1,as ownerose
of the.), INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,BusinessLAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:1'he Contractor's License Law does not apply
to on owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projens with a contractor(s)licensed PUrsumtl to
life Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.In,this WATER HEATER W/VENT 6.00
reason
Owner Data WATER SYSTEM 5,00 ACG DATE ACC.FILE NO.
WORK ERS'CONIPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a carifeme ofcnnsent ID self-insure ZONING ENG.SITE NO.
/ or a certificate of Workers'Compensation Insurance,or a certified
T copy thereof(See.3800,Lab.0
Y Policy No
ert Conger N6:nF
Q 0 Certified copy ixs file furntsm dII FIRESPRINK ENERGYT-24
Z Z 0 Certified copy is filed dh the city inspection division. MISC.- REFER TO ORD.
O_! Applicant Y ❑ N❑ Y ❑ N❑
Cr N CERTIFICATE OF EXEMPTION FFRRO..V WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W 7 COMPF'-NSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O mpl
(This section need not be coeted if the permit is for one �' TOTAL Y❑ N❑ 'Y ❑ N❑
D Z hundred dollars l$100)or less.)
U O 1 certify that in Ota performance of the work for which this per- CITY MECHANICAL PERMIT FEE FEE SUMMARY
.LL I- mit is issued, I shall not employ any person in;my mariner so as to
O W become subject to the Workers'Compensation Laws of Calitorniu.
0- Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} w NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z- enlption,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.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10000C.F.M.) 6.00 SEISMIC FEE
I hereby affirm 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,Civ.C.l. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name 10�YRA"r HEATI NG UNIT 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
-I certify that I have rend this application and state that the above VENTILATION FAN (SINGLE) 4.00 -_
® information is correct.1 agree to comply with all city and County PLUMBING
(3
ordinances and state laws relating to building construction, and BOILER-OOMPH.P.or 100,000 B.T.U.) 6.00 L�( '-`-
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL �/V
uhove ntioneit property for inspection purposes. _
(W a ce m save, indemnify and keep harmless the City of misc.- REFER TO ORD.
Cuperli o a ainst liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
'n ny ay-accrue against said City in cc nsequence of the _ v]
grand f
If
pttndt MECH.CONT. LIC.NO. MECH.
TOTAL �-� TOTAL
ig, o 4 n factor la
INSPECTOR COPY