9513 PLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FIC TION `J PERMIT NUMBER
' a DRES APPLICATION & PERMIT
A1q1DREs �U� '.� l.. r s a
11 w BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 951
I 1 NAME S - rr, e. .�. `! i ` - - _ - PLAN CHECK VALIDATION
T U_ tTY: ELECTRIC PERMIT FEE
PHONE
CON OACTORS
NAME �. OUTLETS-SWITCHES-RECO 10.00/1.00 ,Q7'
y •- y( wo. LIGHTING FIXTURES 10.00/1.00 ��
Co RACTO 's - / APPLIANCES-RESIDENTIAL' 4.00
/ ADDRESS
` - Q,J1 HONE - PANELS 10.00 DATE OF APPLICATION
;,i PLAN PLAN CHECK FEE P.C.N0.
L '11(� c,. ( PANELS (OVER 200 AMP) 20.00
GINEER T it
+;{J" LIC.NO. - SIGNS TRANS.. r !"r 11 '3.00
r PERMIT VALIDATION
ARCH.OR ENG.
a DRESS SPECIALCIRCUIT 5.00
I, ZIP EMP.METER OR POLE INS. 20.00
s
APPLICANT'ADDRESS
ia /) MOTORS SEE FEE SCH.
An�OREss
e
SERVICE CHANGE 20.00
f o oI LICENSED CONTRACT6RS'DECLZRATION r TEMP.POLE 30.00 /�w
G o u,,, I hereby affirm that I am licensed under provisions of Chapter 9 ,Eay ISSUANCE DATE
z w� (commencing with Section 7000)of Division 3 ofthe Business and n < y BLDG. ELECT. PLG. MECH.
a H z Professions Codc d license is in for
full d and • fee v ❑ ❑ ❑ ❑
CLicense Class LIc Number �/
zo L - [)are
o inCO t actor
H
a >< E BUILDING PERMIT
¢ ¢ ¢. j)S. OWNER BOli,DI R DLCLARA(ION..
¢ v -1 - INFORMATION
�ux 3 LL ti I hueby affirm that 1 am exempt from the Contractor's License MISC ' 7k. .rR EF ER'TO ORD
d a_ Law lorthe following reason. 7031.5,Business and Professions PERMIT ISSUANCEY 10 0 VALUATION $/FT
` - Code:Any city or county which requiress permit toconstruct,alter. '
p pair an structure, prior to its iswan ELEC CON LIC.NO.
¢ ¢ o o
improve,demolish,or repair y l a,also ELEC ,/ D
( i ¢ requires the applicant for such permit to file a signed statement that TOTAL
U., w he is licensed pursuant to the provisions of the Contractor's Licen' - PERMIT TO
Hzi
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
a Business-and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
.¢ Io-: •the basis for the alleged exemption.Any violation of Section 7031,5 STORIES TYPE CONSTR.
'6y any applicant for a permit subject,the applicant to a civil penalty gLTER-DRAIN -WATER IEA.) 5.00
6 w
'6f not more than five hundred
op dollars(8500).):
❑ 1,Use at the property,or my employees with wages as OCC.GROUP' RES.UNITS
-- r�-� BACK FLOW PROTECT. DEVICE 4.00
}Inten sole r offered
fo,will the work,and the structure is not
:Codicil or offered for sale (Seca 7044- Business tap) ata Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
;Code:The Contractor's improves
License Law docs and wh y to an owner of - - "
/property who builds or'nprovcs thereon,and who does such work FIXTURES-PER TRAP 5.00 - SO.FT.FLOOR AREA TOTAL ACREAGE
"hies Ifre ar intended
de own employees provided however,
such uuild e-
`ljhi is as through his or employees,ffered for le.Hded that
enipro g GAS-EA.SVSTEM-11NC.4OUTLETS 6.00
',&Improveneat s sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
Iibbildfn III have theburden off,rosln,that he did not build or pn- BUILDING USE
prove for purpose of sale.). RESP IND CON Pe 011ier'
❑ I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ 0 El El ❑
licensed co otraetoo 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
contracts for such projects with a contractods)l icensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I and exempt under Sea .B.&P.C.OrthisHaim WATER HEATER W/VENT 6.00
Owner Date -`' `; WATER SYSTEM 5.00
ACC.DATE ACG FILE N0.
WORKERS'.COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 -
I hereby affirm that ['have a certificate of core nt to s,If im,uic; _ ZONING ENG.SITE N0.
'ora certificate of Workers'Compensation Insurance.or a certif-d
copy thereof(Sec.3800„Lobry. A
Policy N (1 � '13 'f_
Q ❑ Cer d m o Is here g d m FIRE SPRINK ENERGY T-24
Z Z,v• s Certified o y is Eled illi the city inspection division
Oxp �au �"D I/ � _,a MISC. . '_._ AEFERT_O ORD. YET IN Y � NO
- Clikl'1 FICA fI OF E%Eh1PTiON FROM'WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.o
_ Wyrt . PLG. V COMPENSATION INSURANCE PLG.CONTE. LIC.NO ❑ N❑ V ❑ El�! N
Z CAS(This section need not be completed if the penult is for one TOTAL -s
hundred dollars IS 100)or less.)
U 0,;� Tu I certify that in the.performance of the work for which this per= CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL is;
is issued,I shall not employ any person in any manner so ax to
- LL W tic onm subject to theWorkers'Compensation Laws of Californi
y 'Date Applicant' - ,�+ ALTER OR ADD TO MECH. 5.00 BUILDING
>_ (C NOTICE TO APPI ICANT:f1f,•afte making this Certificate of I x�
F_ Z_ eruption,you should become Subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, YOU must forthwith comply with FEE
CJ , such provisions or this permit shall he declared revoked. AIR HANDLING UNIT(TO 10)000C.F.M.) 4.00
r p CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IQOOOC.EM.) 6.00 SEISMIC FEE
I J 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(Sea MICROFILM 'r
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
C( L`ender's NamAdde HEATI NG UN IT E R 100,000 B.T.U.)9.50
L lad r Addri. �^ ELECTRIC
1 certify that I ha a read this application and stain that the above VENTILATION FAN (SINGLE) 4.00
r %d formatio R car et',I agree to comply with all ity and county PLUMBING
• od'nad IS and state lows relating to building eonstruefon, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
'I h baby authorize representatives of this city to eniu upon the BOILER-COMP Cssr,100,000 STU)SEE FEE SCH. MECHANICAL
appffbo e-mentioned property for inspection purpo'I"
A,(We) agree to save indemnify and keep harmless the City of MISC.- REFER TO ORD.' ,
CRintino against liabilities,judgments costs and expenses which CONST.TAX
my in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 •-
MingDfthis p it MECH.CONT. LIC.NO. MECH,
W ]TOTAL TOTAL
m u P del radar ate
INSPECTOR COPY