15006 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
IlUILDING PROJECT I DENTIFICATION PERMITNUMBER -Ly..
WCD,N / A APPLICATION & PERMIT
OFESS
�. �0/ 7 BUILDING—ELECTRICAL—PLUMBING—MECHANICAL OOO,O
OWNER'S PLAN CHECK VALIDATION
AME QTY. ELECTRIC PERMIT FEE
• ` �• PHONE
cgNTRACTORs UTLETS-SWITCHES-RECEP 10.00/1.00
U.NO. AJ LIGHTING FIXTURES 10.00/1.00
CONTRACTOR s APPLIANCES-RESIDENTIAL 4.00
ADDRESS
Q PHONF� PANELS 10.00 - DATE OF APPLICATION
OORRCRITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH.RENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
21P
EMP.METER OR POLE INS. 20,00
�^
APPucnnrs
ADDRESS MOTORS SEE FEE SCH. `// //_'''�-vn-x-�-•. - .--
- _
SERVICE CHANGE - 20.00
o o LICENSED CONTRACTORS DECLARATION / O
a i u 1 hereby affirm that 1 am licensed under provisions of Chapter 9 s• ISSUANCE DATE - I
Nay (commencing with Section 7000)of Division 3 of the Business and _ BLDG. ELECT. PLG. MECH.-
' F . z Professions Code,ynQ,flTlicense is in full for e u d effect ❑' ❑ -
z o In License CL --'lass Q_Gy Lic.Nmnher - �-
Z r Date^7°"'- jf) Contractor
¢Y s BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION
¢ w
X ;LL r I hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD
y VALUATION
F u o a Law for the following reason.(Sere. uiresa,Business and Professions PERMIT ISSUANCE -10.001
,A i Code:Any city or countypair any sequins¢p prior
reconstruct,alter,also
IS
2 a o improve,demolish,or repair any structure,prior w its issuance,also ELEC.CONTR. LIQ NO. ELEC. `
a g O ed exec u requires tire tion.Any
applicant for such permit to file a signed statement that TOTAL PERMIT TO
$ he is licensed pursuant to the provisions of the Contractor's License ?�
a z i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Codthe)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE -
¢ $ the basis for e alleged e yviolation nf Section 7031.5 STORIES TYPE CONSTR.
i3 by any applicant for a permit subjects the applicant toa civil penally ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars 85001.1:
❑ 1,as owner of the property,or my employees with wages as ggCK FLOW PROTECT.DEVICE '4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for Sale(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 6 FIXTURES-PER TRAP 5.00 76 SQ FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees.provided that such improve- _
mems are not intended or offered for sale.If.however,the building ' / GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
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 im- RES 'IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE IN 30.00
❑ Las owner of the property,am exclusively contracting with ❑ ❑ ❑ -❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 14 5 V.B. 0 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply -
to an owner of properly who builds or improves thereon,and who LAWN SP RINK LERS-OV 5 I
contracts for such projects with a contructons)licensed pursuant to SEWER-SANITARY-ST A.200ft/100 �f
the Contractor's License Law. - TRACT NO. PARCEL N0.
❑ lamexemptunder Sec. ,B.&P.C.I'orlhis WATER HEATER W/YEN
reason
Owner Date WATER SYSTEM 5.00
ACC.GATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 '
1 hereby affirm that 1 have a certificate of consent to tel&insure, ZONING ENG.SITE NO.
O
r a certificate of Workers'Compensation InjjSpppmI I"or a certified
copy thereof(Sec.3 Lab.C.).
Policy N.,—Co mpany
❑ Cetlilied copy ie hereby furnished. FIRESPRINK ENERGY T 24
Z ❑ Certified cy i�filed with 9 e city n ection division. MISC.• REFER TO ORD.
O Applicant Y ❑ N❑ Y ❑ No
� N CERTIEICATEOF E%EMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.L.
W COMPENSATION INSURANCE PL ONTR. LIC.NO., PLG.
1 O (This section peed not be completed if the permit Is lot one TOTAL Q V❑. N❑ 'v❑ N❑
D Z hundred dollars IS 100)or less.) -
U O 1 certify that in the performance of the work for which this per- OTV MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
0 y Date—Applicant ALTER OR ADO TO MECH. , 5.00 BUILDING
}.W NOTICE TO APPLICANT: If,after making this Certificate of Ex- - '
F- ? emption,you should became subject to the Workers'Compensation APPLIANCE - 5.00 - PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
(� Such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the 3097,performance
Ince of the work for which this permit is issued(Sere. UEANIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name IT(OVER 100,000 B.T.U.)9.50 ELECTRICLender's AddrssI certify that 1 veread thisapplication and stale that the aboveN FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBINGordinances and state laws relating to building construction, and (3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon theP'(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property far inspection purposes.
(We) agree to save, indemnify and keep harmless the City ofREFER TO ORD.
upe,Ino against liabilities,judgments, costs and expenses which CONST.TAX
ay in any way accrue against said Ci 'o consequence of the PERMIT ISSUANCE 10.00
mntin Ithis permit. MECH.CONT. - LIC.NO. MECH. -
TOTAL TOTAL
ignature of Applicant/Comp6tor Date
OFFICE COPY