9455 g IJ
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY K'
BU LDI NG PROJECT I DENTI FI CATION PERMIT NUMBER
BDILDiNG APPLICATION & PERMIT
X
-� ADDRESS fi �I/ 7t^�+ +
I0elrl A/ WdLFE 'Ili BUILDING-ELECTRICAL-PLUMBING IMEOCHANlICAL 91���
OWNERS PLAN CHECK VALIDATION
NAME(�_y7',e�.�, fEO, SHo E'V63u[La TY. ELECTRIC PERMITFEE 3G.CONTRACTORSXNAME OUTLETS-SWITCHES-RECEP 10.uc.NO. - LIGHTING FIXTURES 10.
r- Acions PPLIANCES-RESIDENTIAL 4.00
/ ADDRESS
• DNE _ PANELS 10.00 --
DATE OF APPLICATION
OR
RC CT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE - P.C.NO.
EE EER
uc.No. SIGNS TRANS. 3.00
ADDDR'ESS ErvG. SPECIAL CIRCUIT 5,0Q PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLICANT$
ADDDRESSDRESS - MOTORS SEE FEE SCH. (Id•-(�/-Q,��
SERVICE CHANGE 20.00
0 o O LICENSED CONIRACTORS DECLARATION TEMP.POLE 30.00
Fi w 1 hereby.]'firm that I am licenwd under provisions of Chapter 9 ISSUANCE DATE
a d (comnsncing with Section 7000)of Division 3 of the llusm,ss and BLDG. ELECT. PLG. MECH.
F'mi m Professions Code('�nit�m�l�icqense is in full force nd a fee t
z U w Locant,Class -+y�•v'Lic.Number ❑
U w Date £(r,.S3-ems Contractor
a x s BUILDING PERMIT
¢ a a OWNER-BUILDER DECLARATION
A o a U • INFORMATION
X g LL I herchy affirthat 1 am exempt frothe Contractor's License MISC.- REFER TO ORD
to m m VALUATION $/FT.
F LL U .AT Law fertile following reason.(Sec 7031.5.Nosiness and Professions PERMIT ISSUANCE 10.00 ..
Code:Any city 0r county which requires a permit to construct.alter,
QQ Q 0 Improve,demolish,Or repair anv Structure',prior t0 its Issuance,also ELEC.CONTR. LIC.NO. ELEC.
a W m¢ requires the applicant for such Permit to]Ile a Signed statement that TOTAL J PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License _
H z i
Law(Clmpter9(commencing with Section 7000)of Division 3 of Ute �,���• 7C
a intones,and Professions Code)or that he is exempt therefrom and QTY, PLUMBING PERMIT FEE
E i D
¢ n- o the basis for the alleged exemption.prion.Any violation of Section malty 'STORIES TYPE CONSTR.
A. by ofeco more HIS fora permit subjects 500Llicanttoacivilpenalty ALTER-DRAIN -WATER (EA.) 5.00
of not more Ulan five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:1'he Cant...let'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 SQ FT.FLOOR AREA TOTALACREAGE
• himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If.however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, - . - . .00 the owner- GAS EASYSTEM OVER 4 (EA) 2
builder will have the burden of proving that he did not build or im- BUILDING USE
prove COT purpose of sale.). INDUSTRIAL WASTE INTER. 3000 RES IND CON PB Other
❑. I,as owner of the property,am exclusively contracting .
with 11 El El ID 1:1licensed contractors 10 construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Cod,: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 Contractor's
License
ts LwithacontrectolVs)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL N0.
❑ l am exempt under See.-,R&P.C,for this. WATER HEATER W/VENT: 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACG FILE NO,
WORK ERS'COMPF-NSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
�l colic INo flSec. Co Lah.C.)//
PolicyNois he n
Q Certified copy is heocbd with the
FIRE SPRINK ENERGY T-24
z Z Certified copy is fled with the city inspection Division.
MISC.- REFER TO ORD.
2" APPicant y ❑ ry❑ y ❑ ry❑
~ rnPERMIT ISSUANCE 10.00
� CISR'I'IFIG\'I'E OF IiXEhl l"PION PROh1 WORKERS FLOOD ZONE A.L.UL.
W COMPENSATION INSURANCE PLG.CONTR. LIC.N0.^ PLG.. .. ,!'
CL Z • (This action need not be completed it the permit is for on, TOTAL- y❑ N❑ Y ❑ N
hundred dollars Of 00)0r less.)
U O A I certify that,in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F ,' mit is issued,I shall not employ any person in any manner so as to
QW become subject to the Workers'Compensation Lows of California.
n Date Applicant BUILDING
} to NOTICE TO APPLICANT': If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
� ? emption,you should become subject to the Workers''Compcnsatmh APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE 3
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.NL) 4.00
CONST RUCHON LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE S�
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.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC 3G.
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to connply with all city and county PLUMBING
oninances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00
hereby anflum , representatives of this city lcenter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-men'Ime)7 property for inspection purposes.
( agree o save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
ertino g' nst liabilities gmen[s, costs and expenses which CONST.TAX
may in a way action g'' st Said City in conseyucncc of the PERMIT ISSUANCE 10.00
granting his permit. MECH.CONT. LIC.NO. MECH. Ct,�
♦ TOTAL TOTAL
ignaturcot ppli t ontractor ate -
INSPECTOR COPY