9495 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATION
PERMIT NUMBER
BUILDING APPLICATION & PERMIT
AD 9495 fl ��
AooREss
21 Z �CGD�up D _ BUILDING -ELECTRICAL-PLUMBING-MECHANICAL `�' L�
OWNER'a I PLAN CHECK VALIDATION
QTY. ELECTRIC PERMIT FEE
D 1r�
PHONE �
CONTRACTOR'S
'2fry ME // L /G �OUTLETS-SWITCHES-RECEP 10.00/1.00
�6s0' p(Lt S �!/re&ILIC.No.G//i LIGHTING FIXTURES 10.00/1.00 r
CONTRACTORSAPPLIANCES-RESIDENTIAL 4.00
T AooR Ess ^ U C�
S wl� /We 1NFRONE ZoS PANELS 10,00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE D.C.NO.
OR
O
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH ESS E "G SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP. METER OR POLE INS. 20.00
APPLICANTSMOTORS SEE FEE SCH.
ADDDREDRESSS
SERVICE CHANGE 20.00 /P
TEMP.POLE 30.00
o o LICE NSED CONTRACTORS DIiCLARATION
¢ U o I hereby affirm that I am licensed under p,.vPions of Chapter 9 `,. ISSUANCE DATE
wi (com encin with Scaion 7000)of Division 3 of the Business and
a K BLDG. ELECT. PLG. MECH.
F m i Professions Code,and my license is in full force and effect. El El El z a License Class Lie Nm i1wr
g - Dale Contractor
¢ m E BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION
a a u INFORMATION
st u y 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD yq LUATION $/FT.
F .. 0 a Law for the fullowi^g reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requiresa permit to Construct.alter,
¢Q o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC.
Bar
0 LL requires the applicant for such permit to file a signed statement that TOTAL S PERMIT TO
w a he is licensed pursuant to the provisions of the Contractor's License
rzr
Law(Chapter 9(commencing with Section 7000)ol'Division3ofthe
a Ilusfnes,and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r o the basis for Ore alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n ; m by any applicant for a permit subjects the applicant too civil penalty
of not more than live hundred dollars($500L). ALTER-DRAIN& VENT-WATER (EA.) 5.00
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP REB.UNITS
then sole Compensation,will Ao the work,and the stmctue i,not
intended or olfemd for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contmetoi s License Law does not of Ply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 s0.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such""prme-
mentsarc not intended oroffered for sale.ll,however,tie building GAS-EA.SYSTEM-l1NC.40UTLET$ 6.00
Login- venwnt is sold within one year of completion, the owner-
GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving tlmt he did not build or int- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INT ER. 30.00
❑ I,as owner of the properly,am exclusively contracting with ❑ El El E] 1:1
licensed Contractors to construct the project(Sea 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 a contractogs)licensed pursuant to SEWER-SAN V-STORM EA.2001t/10.00
the Contractor's License Law. TRACT NO, PARCEL NO.
❑ I am exempt under Sec.-,IL&P.C.for this WATER HEATER W/VENT 6.00
reason
• Owner Date WATER SYSTEM 5.00
G_\ ACC.GATE ACC,FILE NO.
WORKERS'COMPIiNSAi7ON DECLARATION WATER TREATING EQUIP. 5.00
I hereby alfirm that I have a certificate at consent to,eel Ginsure, ZONING
or u certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec 3800,Lab.C.l. -
Policy No:- Company
❑ CertdPd Copy is hereby furnished. FIRE SPRINK ENERGY T 24
z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
Q- Applicant Y ❑ No Y ❑ N❑
w PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. /
�
CERTIFICATE OF EXEMPTIOION N FROM WORKERS'
LOU COd not be completed
iftheINSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ N❑ Y❑ ❑
0 Z (This section need not be complCmd if the permit is for one TOTAL N
hundred dollars(5100)or less)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
UL H mit is issued,I shall not CmpI y any persn^i^any manner so as to
O w hecom�u�subJ�'e��n tq�t�pe Workers mPensa 'n n Laws of California.
0- Dotes 7 10 APPLICANT:
i ALTER OR ADD TO MECH. 5.00 BUILDING
M NUII IO,APPLICANT: IL a ter making this CCN ificae of lix-
F" ? entption,you should become subject¢m the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
Provisions of the [.shot Code, You must forthwith comply with FEE '
I
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT ITO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER 10MC.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.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC 4__'110
1 certify that I have read this application andstate that the above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating no building construct ton, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 L`
hereby authorin representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above mentioned property for inspection pumoxs. +++ LLL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
ertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
onto 'n any way accrue against said City in consequence of the
gr nti of this perm iL MECH.CONT. LIC.NO. MECH.
g• ��-�j- TOTAL TOTAL
Sig marc of Applica t/C ntmctor Dutc
INSPECTOR COPY
I