C8525 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY1
BU LDI NG PROJECT I DENTI FICATI ON P RMIT NUMBER
aDURESS APPLICATION & PERMIT
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
85 5
PLAN CHECK VALIDATION
NAVER/����' y �y���y/ :f fg'OQTY. ELECTRIC PERMIT FEE w_ r
{rel M1a+J V/ /"`�r\' iHONE ��' // 1�j
CONTRACTOR'S
L V
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00 a' f" yam fes_
bF Cy ,No. LIGHTING FIXTURES 10.00/1.00
rRT Acro s APPLIANCES-RESIDENTIAL 4.00
`/ AODR Ess �
\ F .ONE L 5/ j PANELS 10.00 DATE OF APPLICATION
on Irscr PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
� { ' LIC.NO. SIGNS TRANS. 3.00
ADDRESS cera SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP fTEMP.METER OR POLE INS. 20.00
ASI MOTORS SEE FEE SCH.
ADDREDDRESSS
SERVICE CHANGE 20.00
• w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a v I hereby affirm that I am-licensed under provisions of Chapter 9 ISSUANCE DATE
c, A u (eunmencing with Section 7000)of Division 3 of the Rusiness and
A BLDG. ELECT. I PLC. MECH.
ry z Professions Code,and my license is in full force and el7ett.
Z o m - Liccnsc Class Lic.Numtic �f ❑ ❑ ❑ ❑
oDate Conlacmr
< x 2
KX-
¢ ¢w a OWNER-BUILDER DECLARATION BUILDING PERMIT
E: o,A u INFORMATION
w LL I hereby affirm Ihuill am exempt from the Contractor's License MISC.- REFER TO ORD r
Fwo� Law for the following mason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 10.00' ) VALUATION $/FT-
Code:Any city ouepunty which requires a permit to construct alter,
¢ 2 a o improve,demolish,'or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
A
-G LL requires the applicant for such permit to file a signed statement that - TOTAL
w m the is licensed pursuant to the provisions of the Contractors License PERMIT TO
,v Law(Chapter 9(eummenuing with Section 700(Ioffovision 3 ofthefAieSC..Gr 4
- er Business and Profmsiuns Code)or thin he is exempt therel'ronl and QTY. PLUMBING PERMIT FEE
IS r c the basis for the alleged exemption.Any violation of Secli r,7031.5 STORIES I `TYPE CONSTR.
n ; m by any applicant for a pennil subjects the applicant 1.a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of yDt more than Five hundred dollars(5500).):
❑ 1,as owner of the property.or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (See. 7044, Business and Professions DRAIN$-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 SQ FT.FLOOR AREA TOTALACREAGE
• himself re through his own employees,Provided that such im building
mmselfo through
ot his or employees,ffered for molded that s the budding GAS-EA.SYSTEM-11NC.40UTLET$ 6.00
or improvement is sold within one year of completion, the owner-
builder will have tire burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove fur purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB other
❑ I,as owner of the property,am exclusively contracting with El ❑ F1 ❑ 13licensed contractors 10 construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 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 y contractions)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ Iain exempt under Sec.-,B&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dane WATER SYSTEM 5.00 `ACC.DATE ACC.FILE No.'
WORKERS'COMPENSA'I'[ON 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.
copy thereof(Sec.3800, gamy ).
Policy No.• ompany
O ❑ Ccrld" ccopy l5hereby fumnh � FIFESPRINK ENERGYT241
Z z §� Certified copy is Filed with the city inspection division.
F O A(fpriCallt ,,y(g_ MISC.- REFER TO ORD. Y ❑ N❑ Y F] IN
IrN CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
L COMPFNSATION INSURANCE PLG.CONTR. LIC.NO. PL
ZG.
CL (Phis section end not be completed if the permit is for one TOTAL V❑ N❑ Y ❑ N❑
hundred dollar,IS 100)or lessJ
U O 1 certify that in The performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
L H mil is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
Q. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING -f-0
} to NOTICI?TO APPLICANT: IL after making this Certificate of Ex- --
F 2 emptihn,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the labor Code, you most forthwith comply with FEE
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.1 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
7 hereby affirm that there is a constr ction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 s -
the performance of Ihe•work for which this fiction is issued(Sec. MICROFILM
3097,Civ.C.T HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lenders Address ELECTRIC
Ivend, that lhaveread this application and slate that the above VENTILATION FAN (SINGLE) 4.00
•
information n correct I agree to comply with all cep'and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and a re laws relining to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
4-4
pro crty for nspectlon purposes.
o ave end mn7il'y and keep harndess the City of MISC.- REFER TO ORD.
st iahilit judgments, costs and expenses which CONST.TAX
y'accrugta .inst aid City in Consequence of the PERMIT ISSUANCE 10.00e it. V MECH.CONT. LIC.NO. MECH.
TOTAL TOTALfs�"
Sigdv or ut �--
INSPECTOR COPY
1 I