9242 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LOI NG PROJECT I DENTI FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADD ss BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
9242
OWNER'S PLAN CHECK VALIDATION
NAMEI b rl k�/ .36� OTY. ELECTRIC PERMIT FEE
PHDNE
CONTRACTORS
NAM y OUTLETS-SWITCHES.RECEP 10.00/1.00
/'PL',� 'A; Jac.Net IIID LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S
Arflsss APPLIANCES-RESIDENTIAL 4.00
,Q. PHONE 'Q y PANELS 10.00 DATE OF APPLICATION
ORcNliaci PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE• P.C.NO.
ENGINEER
LIC.NO. ISIGNS TRANS. 3.00
ARCH,OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT'S
Nra MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
Doo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a u 1 hereby affirm that I am licensed under provisions ofChapter 9 ISSUANCE DATE
y< i (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH,
F N i Professions Code 1 license is in full force ❑ ❑ ❑
Z,Z H D Eatc a Class Con Number -
Uatc Contractor
Q y E J
a W Q OWNER-BUILD17R DECLARATION BUILDING PERMIT
is D A U INFORMATION
X g U.E. 1 hereby affirm that I am exempt from the Contractors License MISC.- REFER TO ORD
u O Q Law for the following reason.(Sec.7031.5,Businessand Professions VALUATION $/FT.
- N PERMIT ISSUANCE 10.00 �SOD6�
E W 0f Code:Any my or county which requires permit to<onstn¢L alter,
Ie ¢Q D improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. r
D s requires the applicant for such permit to file a signed statement that TOTAL
he is licensed pursuant to the provisions ol'the Contractor's License PERMITTO
F z rt Law(Chapter 9(commencing with Section 7000)of Division 3o fine C"R�- iN�J �',�s(•
4 D Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
le I- $ the basis for tlm alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
A , by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER MA.) 5.00
of not more than five hundred dollars(S500).1:
❑ I,as owner of the property,or my employees with wages us BACK FLOW PROTECT. DEVICE 4.00 Oce.CROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and ProfessionsDRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.60 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsamnotintendedoroffered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 8.00
or improvement is sold within one year of completion,the owner. GAS EASYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im - . BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 REB IND CON PB Omer
❑ 1,as owner of the property,am exclusivCIY contracting with RE El 11licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLER$-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
El 0
and Professions Code:The Contractor's License Law does nol apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant In
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
reasonl um exempt under sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
Owner ])life WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORK ERS'CONIPENSATION DECI•ARA'TION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent to selPinstim. ZONING ENG.SITE NO.
or a certificate of Workers'CGmpensa' n Insu runce,ora certified
copy thereof(Sec.3800,Lab.C.l. ,�,� "T•4u�wC
Policy Nn. nmpany-
0 ❑ Certified hereby tis 8.
Z Z O Certified is 1 wit a Ily inspection division. FIRE SPRINK ENERGY T-24
F 0 Applicant MISC.- REFER TO ORD. Y ❑ NE] Y ❑ No
CC L2 CERTIFICATE OF FX17MPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU COMPENSWION INSURANCE PLG.CONTn, LIC.NO. PLG.
CIL O ('This section need not be completed if the permit is for one TOTAL V N� Y❑ N�
� Z hundred dollars($100)or less.)
U 0 1 certify that in the performance of the work for whicll this per. OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued, I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
U lU Dam A licant BUILDING / a
} y NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00 !�0
Z emption,you should become subject to the Workers'Compensation APPLIANCE' 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER l0,000C.F.MJ 6.00 SEISMIC FEE 0'
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. MICROFILM
3097,CN.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name H EATI NG UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify (list l have read this application and Stam that the above VENTILATION FAN (SINGLE) 4.00
information is correct.1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 HA or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
CAt
gainst liabilitie dgmenbs, costs and expenses which CONST.TAX
way cru aga ns said City in consequence of the PERMIT ISSUANCE 10.00
1granhi p lit. MECH.CONT. LIC,N0. MECH,es, TOTAL TOTAL pplicant/Cn n tract Date
OFFICE COPY -