18830 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT I.
ADOFE55
D.7QQ C` rN , BUILDING- ELECTRICAL-PLUMBING-MECHANICAL 18830
OWNER 1 PLAN CHECK VALIDATION
NAME 996 -nQ 1 OTV ELECTRIC PERMIT FEE (3
NAM[HAcrDRs OUTLETS-SWITCHES-RECEP 10.00/1.00
U// //6 uc.No. LIGHTING FIXTURES 10.00/1.00
DOTRACTOR'S PPLIANCES-RESIDENTIAL 4A0
AHESSly1
O 7 IHONE -O�vv PANELS 10.00 DATE OF APPLICATION
R HITEer Se PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.c.NO,
OR
ENGINEER!/
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ADDRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
ADDRESS s MOTORS SEE FEE SCH. �'�ITO
�A(r. r, SERVICE CHANGE /�M .20.00
w O o LICENSED CONTRACTORS DECLARATION D,
a v U I hereby affnn that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
wBLDG. PLG. MECH.
z w (commencing with Section 7000)of Division 3 of the Business and
<y ELEC
"a z Professions Code,and my license is in full force and effect ❑ El 11o i m W License Class Lic.Number
w r Date Contract.(
J
m cc ¢ OWNER-BUILDER DECLARATION BUILDING PERMIT
a ac a v INFORMATION
L. I hereby'affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u0j Law for the following reason.(See.7031.5.Business and Professions PERMIT ISSUANCE VALUATION $/FT.
impCodrove.
Any city or county which structure permit toc.nsuance.alsalter,
Ze 4&99
CX K O Improve,demolish.or repair any structure,prior to its issuance,also ELEC.DDNTR. LIC.NO' ELEC. �]
a w s LL requires the applicant for such permit to file a signed statement that TOTAL�C 4V� PERMIT TO
he is licensed pursuant to the provisions of tile Contractor's License
Uzi Law(Chapter 9(Commencing with Section 7000)of Division 3 ofthe
Qo Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a;m by any applicant for a permitsubjects the applicant to a civil penally
of not more than five hundred dollars($500).1ALTER-DRAIN&VENT-WATER (EA.) 5.00:
❑ I,as owner of the property,or my employees with wages as BACK 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 .It (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 5.00
Code:The Contractors 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 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA-SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
prove for purpose of sale), RES IND CON Pe Omer
❑ I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 11 ❑ ❑ O ❑
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 properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractods)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
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACG DATE ACC.FILE NO.
WORK ERS'COMPENSAT "DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have e• ificuLL•.f consent to self-insure.
or a certificate of WJib
s' o t comflon Insurance,or a certified ZONING ENG.SITE NO.
copy'thereof(Sec.3b. .
Policy No. a
O ❑ Certified re furnished. FIRE SPRINK ENERGY T]4
Z Cert crit d with city inspection division. Y ❑ NO Y ❑ N�
FO plicant MISC.- REFER TO ORD.
w CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.0 - FLooO 2OrvE A.L.u.c.
W COMPENSATION INSURANCE PLG.CONTE. LIC.NO. ", y
Z (This section need not be completed if the permit is for one TOT' Lia f\ ;� a� { �'J 1:1N❑ Y E] NLJ
U O hundred dollars(S)001 or less.)
I Certify that In the performance of the work for which this per- OTY. MECHANICAL PERMITEE7 FEE SUMMARY
LL H mit is issued.I shall not employ any person in any manner so as to
0 become subject to the Workers'Compensation Laws of California,
n Date Applicant ALTER OR ADD TO MECH. 5.001BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
(- ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
U
provisions
such of the this
Code, you must forthwith comply with FEE
P apermit slmll be deenmd revoked. AIR HANDLING UNIT(TO 10=C,F.M,) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 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. MICROFILM
3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 J1,C75 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information n correct. 1 agree to mply with all city and county PLUMBING
ordinances and sat laws rel. g 1. building construction, and BOILER-ODIVIP(3 H.P.or 100,000 B.T.U.) 6.00
hereby ant hori r it ar sof this city es enter upon the �^ L✓,
aboveemention 801 LER-COMP (Over 100,000 BTU(SEE FEE SCH. e.. oo
p p tY Inspection purposes. MECHANICAL
lent 10 'a C. mnify and keep harmless the City of misc.- REFER TO ORD.
uperti .in bi' ,judgments. Costs and expenses which CONST.TAX
may i w against said Ci in consequence of the PERMIT ISSUANCE .1990 e2v
mnY thi MECH.CONT. LIC.NO. MECH.
TOTA�2`�j �p
Sig ure 0 A p'L t/Contractor TOTAL
Uaz< v
OFFICE COPY