C8256 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT lDENTIFICATION PERMIT NUMBERAPPLICATION & PERMIT
BUILDING
AOOREss
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL8256
PLAN CHECK VALIDATION
A E ' 1 �7V. ELECTRIC PERMIT FEE
c NTRACTOR'S 1
{ NAME 5 OUTLETS-SWITCHES-RECEP 10.00/1.00
N Tic,No. Z LIGHTING FIXTURES 10.00/1.00
FADDRESS DDRESS PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
Om
ciccT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.No.
R
ENGINE '
SIGNS TRANS. 3.00
ADDR.SS ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00 ,
ilv I (� EMP.METER OR POLE INS. 20.00 -
A ucANrs MOTORS SEE FEE SCH.
AliiADDR[SS
I k/,U
L&4-, SERVICE CHANGE 20.00 Id
L
,o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 /�"r/a
a v I hereby affirm that I am licensed underprovisimU,;f Chapter9 ISSUANCE DATE
wr (comanencing with Section 7000)of Di our,3 of the Business and A BLDG. ELECT. PLG. MECH.
y- Professloos so d license is in full foyy��.pLd effej.
z o m - License Class Lic.Number�'I J f1
$m w Dale Commetor
BUILDING PERMIT
¢ ¢w a 'NER-BUILDER DECLARATION
A o a. U INFORMATION
S LL F I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
va v, Law fnr the lbllowing reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code.Any city or county which reyuiresa permit to construct,alter, ( l7
¢ 2 Q O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. �/ /
am O BE requires the applicant for such permit to file a signed statement that TOTAL
u is
m m he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
Fir
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
aBusiness and Professions Code)or thm he is exempt therefrom and OTV. PLUMBING PERMIT FEE
or F. 0the basis For the alleged exemption.Any violation of Section 7031,5 STORIES TYPE CONSTR.
i ; m by any applicant for a permit subjects the applicant toa civil penalty I
of not more than five hundred dollars($500).) ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ I,as owner of the property,or any employees with wages as BACK F LOW PROTECT. DEVICE 4.00 -OCC.GROUP RES.UNITS
their side compensation,will do the work,and the sl rumure is not
intended or offered for sale (Sec. 7044, Business and ProfessionsDRAINS-FLOOR,ROOF,AR EA, D. 5.00
Code:The Contractor's License Law does not apply to U,owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
O himself re through his own employees,provided that such improve-
hients mself a not through
or offered ee salc.Iided that r,the building GAS-EA.SYSTEM-11NC.4OUTLETS 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 provirig that he did not build or am- BUILDING USE
prove for purpose of sated. INDUSTRIAL WASTE INTER3000 RES IND CON PB Omer
❑ I,us awner of the property,ant exclusively contracting . .
ting with ❑ ❑ ❑ ❑ ❑
liecnsed contractors to construct lite praject(Sec. 7044, Business LAWN SPRINKLERS- 1 INC 5 V.B. 6:00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs 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 contractorls)licensed pursuant to
the Commeom-s License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lent exempt Ruder Set.-,H&P.C.for this WATER HEATER W/VENT 6.00
' Cason
Owner Due WATER SYSTEM 5.00 ACC.OATE SACC.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, ZONING
nr a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copyNo.nl(Sac.3800,Lab.Q!- /] r-
Policy No._ ComW>f,Ii17•%+. CB
•Q ❑ Certifie c you Prcb'ffieAft..- FIRESPRINK ENERGY T-24
Certifie cd fie )whit ate ity inspection division. MISC. REFER TO ORD.
APD an
y ry y N�
to - PERMIT ISSUANCE 10.00
0 - CER'1'IF E01 TI :ROh1 WORKERS' FLOOD ZONE A.L.UC.
LU fPYNSATION INSURANCE PLG.CONTE. ❑C.NO. PLG. [:] ❑N Y[:] ❑
CL O (Phis section need not be completed if the permit is for one TOTAL Y N
Z hundred dollars(5100)or less.)
•U O I certify that in the performance of lire work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
-(y l- mit is issued,I shall not employ any person in any manner so as to
,Ow become subject to the Workers'Compensution Laws of California.
n Date Applicant - BUILDING D 1
} to NO'T'ICE'f0 APPLICANT: 11,after making this CuRificatu of 6x- ALTER OR ADD TO MECH. 5.00
F Z_ emotion,you should became subject to the Worker 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 de00
deemed revoked. AIR HANDLING UNIT(TO 10,0CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE i1U�
1 hereby affimt Oct there is a construction landing agency lit. EXHAUST HOOD (WITH DUCT) 5.00 J'
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 HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that l have read this application and slate that the above VENTI LATION FAN (SI NG LE) 4.00
infora almn is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.Or 100,000 B.T.U.) 6.00 �'•a. _
hereby awhurize representatives of this city m enter upon the BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
xbovcsnentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cu ino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
an it any way accrue against said City in con equcnce of the
g is p nit. -3 MECH.CONT. LIC.NO. MECH.
\ TOTAL TOTAL x,23 Bc
svmtuYttbl�LAp / on acts m e
INSPECTOR COPY