4958 ,APPLICANT TO FILL IN INFORMATION WITHIN RED LINES'- USE BALL_ POINT PEN ONLY
PERMIT.NUMBER
•
BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT
amuneG __ 4.958
AooREsc l O� e„ JNG-ELECTRICAL-PLUMBING-MECHANICALO.NER'5 �S C�-u. PLAN CHECK VALIDATION
N E ELECTRIC PERMIT FEE
. Wry GN 7�^ ' y �-L� 0 _/
CONTRACTORS C/"
rvA�mEr�I, OUTLETS-SWITCHES-RECEP 5.00/1.00 .`3Z /
No 7 LIGHTING FIXTURES - 5.00/1.00
CONTRACTORS
IeigmlREl:il APPLIANCES-RESIDENTIAL 4.00
PRONE (,9-630 PANELS 5.00 DATE OF APPLICATION
AOR
RCHRECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG. PERMIT CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS �- /vT
SERVICECHANGE 10.00 ��
C ¢ z
F o O LICIiNSIiD CONTRACTORS Df CLARATION
a U I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
w<oAi (commencing with Section 7000)of Division 3 of the Bushesyynd BLDG. ELECT. PLG. MECH.
H ve z Professions Coda y license Is in full for eff �/L - E]
Z o w - Licevsc lass Lic.Numbe L/�� '-1 J
o N F � Date�' Contractor
¢ a w a OWN�DER DECLARATION
BUILDING PERMIT
o w . MISC.- REFER TO ORD INFORMATION
row .
; w 1 hereby offinm that I am exempt from the Contractor's License TION g/FT.
LL
LL o J Law for the ityroreason.ch e.7031.5,Business and Professions 6.00
- following PERMIT ISSUANCE -
� Code:Any city or county which requiresaperm il to construct.alter, l�
QQQ0 improve,demolish,or repair any structure.prior to its issuance,also ELEC.CONTE. LIC.NO. _ ELEC. d
a. o¢ requires the applicant to,suet,permit to file a signed statement that TOTAL a N Te
a w m n he is licensed pursuant to Dm provisions of the Contractor's License ) ILPER IT TO
rzi Law(Chapter 9(commencing with Section 7000)ofDivision 3oflhe S'aLH L't
E 4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEEni - f T
ac r$ the basis for the alleged exemption.Any violation of Section 7031.5 llai PE CONST .
by otinorapplicant fora permit subjects S500o.he limnuoacivil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more owner
five hundred property,
or
em):
❑ Las owner at the property,or my,and laces with wages as BACK F LOW PROTECT.DEV ICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
'vended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
. himself or though his own employees,provided that such improve-
.cuts are not intended or offered for sale.If,however.the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00
hLilder will have the burden of proving that he did not build or Tin- BUILDING USE
prove for purpose of sale.),thep RES INDUSTRIAL WASTE INTER. 20.00 ❑ I❑ ❑N PIT❑ ❑
❑ L as owner of the property,he exclusively contracting with
licensed contractors In construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
toProfessions property Contractor's License Law does not apply
co an owner of property who builds tr improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1,00
contracts for such projects with a amtmcurrtsl licensed pursumit to '
the Contractor's License Law. - SEWER-SANITARY-STORM EA.200ft/8.00 TRACT No. PARCEL NO.
❑ I am exempt under Sec. .B.RP.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM - 4.00 ACC.DATE. ACC.FILE NO.
WORK ERS'COMPFN'SA1 ION DECLARATION WATER TREATING EQUIP. 4.00
1 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 tile rcyy�{f��I� � 3800,Lah,CJ.
Policy No4(g__Compa"y OSr.C9 � �/�
O ❑ Certified copy is hereby furnished.
❑ Cerlifi is fled tit tte t 'n FIRESPRINK ENERGY T 24
Z Z PY y 5pection division.
Applicant %� MISC- REFERTO ORD. Y ry v N
~ Oy P
ERMIT ISSUANCE Lr - CERTIFICATE OF EXEMPTION FROM WORKERS' 6.00 FLODD ZONE A.L.U.C.
W COMPENSATION INSURANCE LIC.NO. PLG.
O (This sectio" need not be completed if the permil is far one TOTAL Y N V ry
0 Z hundred dollars lS 100)or less.)
U O I certify that in lite performance of the work for which this PerHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 diol]not employ any person in any runner so as to
Q U become subject to the Workers'Compensation Laws of California.
Is. Date Applicant D TO MECH. 4.00
} con NOTICE. TO APPLICANT: If,after making this Ccrtificme of fix- BUILDING s�
F Z emption,you should become subject to the Workeri Compensation 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall be deenned revoked. UNIT(TO 10,000C.F.M.) 3.00 FEE
CONSTRUCTION LENDING AGENCYAIR HANDLING UNIT(OVER10,000C.EM.) 5.00 SEISMIC FEE e�
1 hereby affirm that there is a constnmtion lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of lite work for which this permit is issued(Sea MICROFILM
3097,Civ.CT, HEATING UNIT(TO 100,000B.T.U.) 4.00
Lender's Name
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify that 1 have read this app]icat ion and state that the above VENTILATION FAN (SINGLE) 3.00
ordinances n correct 1 agree to comply with all city and county PLUMBING -o 0'v
ordinances and state laws relating to building construction, and BOILER-ODMP(3 H.P.or 100,000 B.T.U) 4.00
hereby mnhorizc representatives of this city to enter upon the
above-mentioned property
for inspection purposes. BOILER-COMP (Over 100,000 BTU(SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Caper against liabilities,judgments, costa and expenses which CONST.TAX
may in an way accrue a Test mid City in consequence of the PERMIT ISSUANCE 3.00
gra o permit MECH.CONT: LIC.NO. MECH.
j vx, ���' - TOTAL TOTAL ��
S a , pPRc ntractor Date
OFFICE COPY