6167 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADOREss / )�¢J� T 1
'- )VI:%/` �i'/ ' BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 6 1 67
OWNER'S _ PLAN CHECK VALIDATION
/GI PH TV. ELECTRIC PERMIT FEE
/
PH NE
NAMERAcrORs ��/[j/; UTLETS-SWITCHES-RECEP 5.00/1.00
Lt..No. /71'r LIGHTING FIXTURES 5.00/1.00 _
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADOR
L rvE PANELS 5.00 DATE OF APPLICATION
' ARRC TE T SIGNS - 6.00 PLAN CHECK FEE .0.N .
ENGINEER 3-�
LIC.NO �6 SIGNS TRANS. p
ARCH.09 ENG.
SPEC) CIRCUIT PERMIT VALIDATION
MrT
EMP.MET
ADORey-•-�„���'� 5.00
'-'
ZIP ER OR POLE INS.nIfr 15.00, n
APPucArvrs MOTORS I aSEE FEE SCH:
SERVICE CHANGE .* ..P D,10:00;,
AO
o ¢ -'
w LICENSED CUNT RAM ORS DECLARATION
a U w 1 hereby affirm That 1 am licensed under provisions o f Clupe,1) �`�r-y '� OL USSIIAUCDATE
(commencing wit Section 7000)of Division 3 of III anJ
n a N r,gy LOU.BELEC P G. MECH.
H y z Profession COQlMu
w is in full force uA" t. �-
z o M- Licen—se Class/^/ Number
O m r cu 11atc lVContractor- AI I
a x �L7 B' ILOING PERMIT
¢o a OwUCR DIiCIA RATION INFORMATION'
w ; r I hereby affirm that 1 am exempt from the Contracmr's Liceene MISC.- REFER TO ORD
u O j Law for the fnlluwing reason.(Sec.7031.5,Businessand Profisvons O B uPscU $/FT.
r - Code:Any city orcoumywhich reuiresa PERMIT ISSUANCE 6.Op (o pe IQQ
y permitt.Lronaln¢t,,flog
2 Q Q improve,demolish,or repair any structure,prior to its Lcteirce,also FILE ONTR LIC.NO.// C y� O�
d wO u rnluirsx the applicant for such permit to thea,igrshd statement that r TAL OLU45� PERMIT TO
hh 8 licensed pursuant Io the provisma,Of the Contractors License
F 2:a Law(Chapter 9(commencing with Section 7000)of Division3ofthe r"'�
4 O Business and Professions Code)or Ihm hnp
e is exmt therefrom and OTY. PLUMBING PERMIT, FEE S4,/^f i C Y?CU L
I- S the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d ; by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dohns($5000.)
aV/TG.-
❑ I,as owner of the property,or my employees with wages as ' BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their Sole compensation,will do the work,and the structure n not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CONIC. 4.00
Code:1'he Contractor's License Law does not apply to an owner of
properly who builds or Improve,thereon,and who docs such work FIXTURES-PER TRAP 4.00 SO.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employes.provided that such improve- .
meals are not intended or offered for side.If,how eve r,the building GAS-EA-SYSTEM-11 NC.4 OUTLETS 4.00
or hnprovemesd is sold within one year of completion.01e owner- GAS'-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or am
prove for purpose at Sale.). INDUSTRIAL WASTE INTER. 2000 RES IND CON PB Dan.
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contract.,, t. construct,Ihe project(Sec. 7044,Business LAWN SPRINKLERS-I INC 5 V.8. 5.00 ASSESSORS PARCEL NO.
and Proesslom Code:The Contrx9or's License Law does not apply,
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OV,ER!61(EA.) 1.00
contracts fur such Projects with a contractors)licensed pursuant to
the Contractor's License Law. ' SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ Iamcxcmplundcr Scc. ,B.&P.C.for This WATER HEATER WNENT 1 �C L'
4.00
ower Dam WATER SYSTEM p 4.00 ACC.DATE ACG FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING E_PWI?f CU ertino.00
1 herebyaffirm that I have IT certificate OI consent m sell-insure ZONING
or a certificaAdo
s'Compensation Insurance,or a certifi nd ENG.SITE NO.
copy hereof Lib f.l. a ��
li No. _ _ -
('' Ce eby mished FIRE SPRINK ENERGY T-24
Z z ca t itis division. MISC.- REFER TO ORD. Y ❑ N❑ - v ❑ N❑
O
C[: h PERMIT ISSUANCE 6.00 FLOOD zonE A.L.u.c.
CIiR'I'I PICA'1'1i OP ExEm ON FROM WORKERS' __ -'y //
Lid O need of SATIec INSURANCE P .CON C. TOTAL �-l0 ❑ ❑ '❑ ❑
)This section need nil 4 complcicJ if the permit rsfor o - Y N V N
L) Z bonded J011ars(f 1001 or Icsc)
U O I ertif,that in Ore perlonnuace of the work for which this per- (3TY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner so as to -
O W becona object to the Worker'Compensation taws of California.
Dare nnphum BUILDING Q�•J-0
C. ALTER OR ADD TO MECH. P.A1D 4.00 /o
} N NO'110E TO APPLICANT: If,after making thisCertificate of Ls-
. 2 emption,you should become subject to the WorkersCompensation APPLIANCE 4.00 PLAN CHECK .
provisions of the Libor Code, you must forthwith comply with FEE
U' such provisions or(his peami(shall be themed revoked. AIR HANDLING UNIT(T0il0pODC.F.M.)tC3:00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10PRDC.F.M.) 5.00 SEISMIC FEE 9�
I hereby affirms that thea is a construction lending agency for EXHAUST HOOD(WITH DUCT) UO ;OD
the perlorman ce of the work for which this permit.is issued(Sec MICROFILM
'3077,G,C.). . - HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Addre« HEATING UNIT(OVER 100,000B.T.U.)7.50 ELECTRIC OZD
I artily that l have rood his application and slate that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
brdiumi and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,0008.T.U.) 4.00
her Aria representatives of this city lO enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. L a
J,..y
ned property for i nspection Purposes. MECHANICAL (J�
to save, indemnify and keep Kumla the City of MISC.- REFER TO ORD.
CuiaU liabilities,judgments, costs and expenses which PERMIT ISSUANCE 300 CONST.TAX
conaccrue against said City in onsequence the
gco amiL MECH.CONT. LIC.NO.� MECH.
TOTAL/00 TOTAL S,S"q/
of Applicant/Co motor Date' f �/
• O FIC.COPY