11547 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING
APPLICATION & PERMIT 11547
A DDR E55
!!
�Z/1S � G O BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWrvER.S _ PLAN CHECK VALIDATION
NAME /0 ss /] DTV. ELECTRIC PERMIT FEE
S. PHONE]
CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
N ME
� ' LIC. LIGHTING FIXTURES 10.00/1.00
rorvTRACTons APPLIANCES-RESIDENTIAL 4.00
ADDRESS
z.� ONNO PANELS 10.00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER ��' t
LIC.NO. SIGNS TRANS. 3.00 av
ARCH.OR ENG. 5.00 PERMIT VA
ADDRESS SPECIAL CIRCUIT
ZIP EMP.METER OR POLE INS. 20.00 V V •'
APPLICANTS MOTORS SEE FEE SCH. lo�ib
ADDRESS
SERVICE CHANGE 20.00 .City of
Woo LICENSED CONTRACTORS DECLARATION yuDel`ln�
a it U I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
y a w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. C .
F o i Professions Cod• ane r�license is in full fo{c a d f c. ❑ ❑ ❑
z 0 m G Lice 1� Lie.Nunlh /
2 Date (• -• y Contract f
BUILDING PERMIT
w OWNER-BUILDER DECLARATION INFORMATION
T.
LL N 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
p VALUATION $/FT.
Fu O¢ Law for the following reason.(Sec.703L5.Businessand Professions PER MIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
te 4 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O u requires the applicant for such permit to file a signed statement lila[ TOTAL PE
w$ he is licensed pursuant to the provisions of the Contractor's License •P//�PA_A/V/`-�
Law.(Chapter 9(commencing with Section 7000)of Division 3 Grille
a Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
se o the basis for the alleged exemption.Any violation of Section 7031.5 $TORI 5 TYPE CONSTR.
a ;m by any applicant for handled
subjects(he applicant toa civil penalty ALTER-DRAIN IL VENT-WATER IEA.) 5.00
of not more than five hundred dollars(5500).):
❑ Las owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 oec.GROUP RES.UNITS
their sole compensation,will file work and the structure is not
(S
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law docs not apply Us an owner of
improves
r' property who builds or mproves thereon,and who docs such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
L, himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building
- or improvement is sold within one year of completion,file owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have file burden of proving that he did not build or im- RES IND CON Pe Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 El El El ❑ El
I,as owner of the property,all,exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSE55UHS PARCEL NO.
and Professions Code:The Contractor's License Low does not apply
to an owner of prnperly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts]or such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to selGinsure, ZONING ENG.SITE NO.
or a certificate of Workers'Compe alion Insurance,or a certified
Do
py t of 5•c.3 Lab ).
Police. !yq�'[(', 1(
Q �❑❑// etll l p I tErcbY It rnished. FIRE SPRINK ENERGY L24
Z Z J4„Cer' a co y file with he ty_inspection division. MISC.- .REFER TO ORD. Y ❑ N❑ y ❑ N❑
cc OApplicu f: off
CER'I'IFICA'I'E OF EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
UJ > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL CI (This section lived not be completed if the pennil is for one TOTAL Y❑ N❑ Y❑ N❑
Z hundred dollar,IS 100)or less.)
U O 1 Certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
, H mit is issued.I shall not employ any person in any manner so as to
0U become subject to the Workers'Compensation Laws of California. BUILDING
Date Applicant ALTER OR ADD TO MECH. 5.00
} rail NOTICE TO APPLICANT: If,after nicking this Certificate of Ex-
F.. ? emplion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1Q000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000C.RM.) 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. HEATING UNIT TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.CJ.
Lenders Address Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)8.50 ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with alt city and county BDLER-COM
P(3 P 10 0,000 .T.LL) 6.00 PLUMBING
q ordinances and state laws relating 10 building construction, and
hereby authorise representatives of this city to viler upon the BOILM
ER-CO1 ,0008 SEE FEE SCH. MECHANICAL
' above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of I M R TO ORD.
f-'-Peril B cinst liabilities,judgments, costs and expenses which' I SUA E 10.00 CONST.TAX
may an wa a against said City in c ns• once of the
gra in
of his cr il. MECH.CONT. LIQ NO. MECH.
71� TOT TOTAL
arc of pplicanl Gmr'acigr lu / / e
OFFICE COPY '