17055 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 17055
ADORE
ss
I-LL� L� , BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 1f
DWNER'$ ! PLAN CHECK VALIDATION
• gEr^, -zt7PHONF �S - Z QTY. ELECTRIC PERMIT FEE
P3� 0
CONTRACTORS ( '+ OUTLETS-SWITCHES-RECEP 10.00/1.00
LzA (I(.O LIC.No /�� LIGHTING FIXTURES 10.00/1.00
CONTRACDRs �ll 1�k5 PPLIANCES-RESIDENTIAL 4.00
&S LL)ME- PHONE /�6 1-036 PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.Na. SIGNS TRANS. 3.00
ARCH.OR ENG, 5.00 PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT
ZIP EMP.METER OR POLE INS. 20.00 Q �j
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 1e f9
o o LICENSED CONTRACTORS DECLARATION
3 u 0 1 hereby affirm that I am Iicelncd undo provisions of Chapter 9 "/��^,/" ISSUANCE DATE
m a N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
O z Professions Code and y license is in full lorcJ CK(y'-ItI '� 1�' ❑ ❑
Z O v, - License Class Lic,No U 'rc e /
Contractor
2t. . Dale V/rh
IS w¢ OWNBR-BUILDER DECLARATION BUILDING PERMIT
a o A O MISC.- REF R TO ORD INFORMATION
wLL w I hereby affirm that I am exempt from the Contractor's License VALUATION S/FT.
F w o v, Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 10.00 12.00
Code:Any city or.county which requires a permit to construct,alter,
2 W. 40 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. �( IR
O LL requires the applicant for such permit to file a signed statement that TOTAL L\ )' PERMIT TO
w m he is licensed pursuant to the provisions of the Contractor's License
Hzi Law(Chapter 9(Commencing with Section 7000)ofDivision3ofthe (� SPxr_
4 Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE V V.
r o the basis for the alleged exemption.Auv violation of Section 7031.5 STORIES TYPE CONSTW
i ;m by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN&VENT-WATER IEA.) 5.00
of not mom than five hundred dollars(S500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCD.GROUP RES.UNITS
their Sole compensation,will do the work,and the structure is not
intended or offered for .It (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 So.FT PLOOR AREA TOTALACREAGE
'• himself or through his own employees.provided that such improve- GAS-EA.SYSTEM-1 INC.40UTLETS 6.00
ments are not intended or offered for sale.If,however,the building
or improvement is Sold within one year of completion,the owner GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or ins- RES IND CON PS Omer
Prove for purpose of salol. INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 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 IEA.1 1.00
contracts for such projects with a contractor)s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACTNO. PARCEL NO.
the Contractor's License Law.
❑ I dm exempt Linder 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
1 hereby affirm that I have a certificate of cmlsent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
Copy lhercof I Sec.3800.Lab C.).
Policy No. Company
Q ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is tiled wth the city inspection division. MISC.- REFER TO ORD. Y ❑ N� Y ❑ No
Applicant
F' PERMIT ISSUANCE 10.00 FLOOOZONE A.L.U.C.
-
CERTIFICATE OFF-ATON ION FROM WORKERS*
UJ > need net
be Com INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ N❑ Y ❑ N❑
n- O (This section need not be completed if the permit is for one TOTAL
D 2 hundred dollars(S 1001 or less.
U O 1 certify that in the perfo ane a work for which this per QTA. MECHANICAL PERMIT FEE FEE SUMMARY
LL mit is issued, 1 shall not em toy a perso in any manner so as to
U w
1,-can s }��hcWorkc ' mpan: Ion LalsofCulilornia. BUILDING
hatApplicant / ALTER OR ADD TO MECH. 5.00
} y NOTICE f0 AP LICANT: 11,oiler main• his Certificate of lix-
Z emption.you should bcco -----------the orksm'Compensation APPLIANCE 5.00 PLAN CHECK
U pueh proVisinvisions or tl sof the bor perm tdshall he dcemeou must dl revokted`oI ply with AIR HANDLING UNIT LTO 10=C.F.M.) 4.00 FEE
M.)
CONSTRUCTION LIiND1NG AGENCY AIR HANDLING UNIT(OVER 10=C.F. 6.00 SEISMIC FEE
s 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 ISec. FW
UNIT LTO 100,000 B.T.U.) 8.00 MICROFILM
3097,Ci,C.l.
Lender's Name G UNIT(OV ER 100,000 B.T.U.19.50 ELECTRICLender's Address
I certify that I have read this appli,,rum and su re that the aboveTION FAN (SINGLE) 4.00inlonnation is cormct. I ngrce w comply wdh oil city:Ind countyCON is(3 H.P.or 100,000B.T.U.) 6.00PLUMBING
ordinances and state laws relating to building construction, and
hereby authorieo represenutives OI this city to enter upon the -COMP IOve1100000 BTU)S EE FE E SCH. MECHANICAL
above-mentioned property far inspection purposes.
(We) agree to save, indemnify and keep harmless the City Of REFER TO ORD.ningpe
bilities,judgments, costs and expenses whichISSUANCE 10.00 CONST.TAX
crur, against said City in consequence of the
t. LIC.NO. MECH.
9•IBy TOTAL TOTAL Z LS'GI
/COntmctor Date
OFFICE COPY