1815 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT lDENTIFICATION ERAI BER BUILDING- APPLICATION & PERMIT N 1815
AD E99
,I BUILDI/NG - ELECTRICAL-PLUMBING•-MECHANICAL
NPME y/u'>�Y/� �5 (Q - PLACHECK VALIDATION
�/�
ELECTRIC PERMIT FEE
0
CO • iOR'9
UTLETS-SWITCHES-RECEP 5.00/1.00
LIC.N LIGHTING FIXTURES 5.00/1.00
CONTIjACTOR'S APPLIANCES-RESIDENTIAL '4.00
ADDRESS
L t 'RON PANELS. 5.00 OnrE OF APPLICATION
OR HITECT SIGNS 6.QQ PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No, SIGNS TRANS. 3.00
nooAeea else. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
ADDRES Nr$
ADORES MOTORS SEE FEE SCH. '
SERVICE CHANGE 10.00
o ¢ z JJ
Foo LICENSCU CONTRACTORS UECLs\RA'T'ION
< u w 1 hereby affirm that 1 am licensed under Provisions of Chaptcr 9 - ISSUANCE DATE
,HA Q 'w (commencing ith Section 7,000)of Division 3 of the Puniness and BLDG. ELECT. - PLG. MECH.
F y z Professions y license is in full Io {( ppetH�� �S / •
z o w - Liccns �=L?1� � hie,Number � S9 ❑ ❑
o h Date Comnetor �' IIZ,f 117//lir✓LnK�` \
¢ m : BUILDING PERMIT
¢ ¢ 4 OWNER-BUILDER DECLARATION
d o d o I INFORMATION
w g LL H 1 hereby al'GnJ that 1 an,exempt from the Contractors License MISC.- REFER TO ORD
H LL o Q Law for the following reason.(Sec.7031.5,Busincssand Professions PERMIT ISSUANCE • 6 VALuarION
Code:Any city or county which req uires a permit to construct,alter,
ac 2 ¢ p improve,demolish,or repait any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
A. D¢ requires the applicant for such Ijermil to file a signed statement that - _ TOTAL PERMIT TO
w r� he is licensed pursuant to the provisions Of the Contractors Licenw '
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4Business and Professions Code)or that he is exempt beefrnm and QTY. PLUMBING PERMIT FEE lY
¢ O the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i ; by any applicant for a permit subjects the applicant ma civil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00
of not mora than five hundred dollars 1 S500)J:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITStheir sale compensation,will do the work,and the structure is or inleaided or offered for m1e (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law docs not applyto an owner of
property who builds or noprosves thercmt,and who does such work FIXTURES-PER TRAP, '4.00 Su FT.FLOOR AREA TOTAL ACREAGE
o himself re through disown employees. 1, If.hJ that such improve-
inerthimself
are throughot Jed onemplo for.1, If. that
cmprons GAS-EA.SVSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.1 1.00 BUILDING USE
builder will have the burden of proving that he did not build or int- RES IND CON PB . Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 2000
❑ 1,as owner of the property,am exclusively contracting with . ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the proicet(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. '5.00 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 SPR INKLERS-OVER 5(EA.)' 1,00'
contracts lot such projects with a contrucmds)licensed pursuant to
the Contractor's License law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NOso .
❑ Iamexenlptundcf5ec. ,B.&P.C.for this WATER HEATER W/VENT 4.00
Rea n
Damow"°r' WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'CO%IPENSAT ION DECLARATION WATER TREATING EQUIP. 4.00
I hereby attirm that I have a certificate of consent m s IGinsure' ZONING ENG.SITE NO.
or eniffc c of Worker((�sC/ompenr ti crtifeJ
O r� L �sp s h•cby 11uliiebcd.
z Z CGrI!Iel CO R d x'11 th• Ity1A-"'cil FIRE SP RINK ENERGY T.HA
O A I ,t MISC.- REFER TO ORD. Y ❑' N❑ Y ❑- : N❑
~ w PERMIT ISSUANCE 6.00
- IIICATIi OPIiX IiSIFfION FRON1 RKERS' FLOOD ZONE A.L.U.C.
W CUA1PIiNSA1'ION IN'SURAN F PLG.CONTR. LIC.NO. - PLG. /s Y❑ N❑ Y❑ N❑
O' 1 segidn need not be completed if the permit is for one TOTAL (1
Z hundred dollurs(S l W)nr less.l "
U O 1 ccnlfy that in the performance of the work for which this per- GTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person ie any manner o is H,
U w become subject to the Workers'Compere tion Laws of California.
CL Dam Applicant ALTER OR ADD TO MECH. 4,00 BUILDING
} W NOI'IC17'1'0 APPLICANT: 11;alter,,.king this Certiftcale of
? creation,you should become'sobject to the Workers Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you mon forthwith comply with FEE
U such provisions or this permit shall be dermad revoked. AIR HANDLING UNIT(TO 10MO C.F.M) 3.00
CO "RUCTION LENDING AG17NCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby 011 t at there is a construction lending agency for - EXHAUST HOOD (WITH DUCT) 2.00
the pirl.onan of he wf for which this Ih'nnit is issl cJ(Sec. MICROFILM
31397,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
]-credo's Name HEATING UNIT(OV ER 100,000 B.T.U.17.50
Lenders AJJres ELECTRIC
I antsy the use read this upplicmion and some t t tl uM 'c VENTILATION FAN (SINGLE) 3.00
into"nation rrecl. I agree to rompb' with all y an coon PLUMBING
Iseordinances an state laws relating t0 building mor ion..am1 BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00 V (�
hereby a cd roperty tenses of the city t r upmi the BOILER-COMP (Oser 100,000 BTU)SEE FEE SCH. MECHANICAL
abov n'rued prupeny for inspection purpouv.
L7
a ee to suvc, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Perim ugai it E bilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in .Trey uy ccr a nguimt said City in consequence of the
grand of tis mar MECH.CONT. LIC.NO. MECH.
ezzTOTAL TOTAL Q•d�
m of Appliwn Con ract I t
I�
OFFICE COPY -