11164 APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS 1116 4
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S - PLAN CHECK VALIDATION
NAM ) QTY. ELECTRIC PERMIT FEE 1
Py ' "� )
COPfRLUfTOR S - UTLETS-SWITCHES-RECEP 10.00/1.00
ME 1
LIC.NOLI 1W
LIGHTING FIXTURES 10.00/1.00
f,ONTRACTO 's APPLIANCES-RESIDENTIAL 4.00
EBS
PHD PANELS 10.00 DATE OF APPLICATION
ARCNrtsc PANELS (OVER 200 AMP) ,20.00 PLAN CHECK FEE P.C.NO,
D
EN
Llc.No. SIGNS TRANS. 3.00
ARCH.ORENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER O POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH. /f/f1 `
ADDRESS �\
SERVICE CHANGE 20.00 ` /�-7
wO O LICENSED CONTRACTORS DECLARATION l
<u u -I hereby affirm that I am licensed under provisions of Chapter 9 /uANCE DATE
y <n (Commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H N i Professions Co .d m license is in full to El El z O m- License Cl ss s Lic.Numb
o � Contractor]
a x BUILD NG PERMIT
¢ w ¢ OWNER-BUILDER UECLARA'fION INFORMATION
w LL I hereby affirm that 1 am exempt from the Contractor's License MISC.- R TOORD
VALUATION $/FT.
.. 0¢ Law l'or the following reason.(Sec.7031.5;Businessland Professions PERMIT ISSU 10.00
NJ Code:Any city orcounty which requires a permit to constrUCLalter,
w improve,demolish,or repair an Slmclur¢,poor to its issuance,also EL C.C QTR. L.,I/C.NO. ELEC.
¢ ¢ a O r pY ��Cl�
o LL
requires the applicant for such permit to file a Signed statement that TOTAL J PERMIT TO
u w es he is licensed pursuant to the provisions of the Contractor's License
z i
Law(Chapter 9(Commencing with Section 7000)of Division 3 ofthe LG
¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
P x O
m $ the basis for the alleged exemption.Any violation of Section STORIES TYPE CONSTR.malty
by any applicant fora permit subjects S500).licamwacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
�..
of not marc owner
Ove the prop dollars(55 employees
O 1,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 sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00 '
Code:The Contractor's License Law does not apply to an owner of
property who builds or impmves thereon,and who does such work FIXTURES-PER TRAP 5.00 BO.FT.FLOOfl AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mu GAS-EA.SVSTEM-i INC.4OUTLETS 6.00
enare not intended or offered for sale.If,Imweeer,the building
or improvement is'Old within one year of Completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
in IdeT will have the burden of proving that he did not build or im- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 El El 11 13 El
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-OV ER 5(EA.) 1.00
Contracts fol such project with a contractoo s)licensed pursuant to
the Contractor' License Law SEWER-SAN ITARV-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lamexempt ec. .B.&P.C.nor this WATER HEATER W/VENT 6.00
reawn
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSAi'ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure. ` ZONING ENG.SITE NO.
or a certificate of Workers'Co-3 Ins ra e,or certified
copy thereof(See 3800,Lab.0
Policy No. Company '�-Q(_Y�I-�-
❑ Certifies.-_'opy is hereby fur nis ed FIRE SPRINK ENERGYTYO ^
Ic iq�("dW-With the t y`�•cI dnision. MISC.- REFER TO ORD.
Z ZO App(cunt /S( p0 1'� f� / f f hf Y ❑ N❑ Y ❑ N❑
F-- yPERMIT ISSUANCE 10.00 FLOOD ZONE . A.L.U.C.
CC - CERTIFICATE OF IiXEMPI'[ON FROM WORKERS'
LU > COMPENSATION INSURANCE PLO.CONTR. LIC.NO. PLG. Y❑ N❑ Y Q N❑
C O (This section need not be completed if the permit is for one TOTAL
Z htmdreddoIImrS(S100)mIC..)
U O 1 certify that in the performance of the work I'or which this per- DTV. MECHANICAL PERMIT ` FEE FEE SUMMARY
LL H mil is issued,1 shall not employ any person in any manner so as to
' Q W
become^ 'ems the Workers'Compensation Laws of California.
'• BUILDING
Date- T" ALTER OR ADD TO MECH. 5.00
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F" Z emption,you should become subject to the Warkeri 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 10,00)C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 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 AddHEATI NG UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
ress
I certify that l have read- Lsapll'�rznd State that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county BOILER-COIL)H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,1100 BTU)SEE FEE SCH. MECHANICAL
' \ a -mentorroperly for inspection purposes.
(WV
ave, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cuperamiilies, d is nd expenses which CONST.TAX
m ecrue ago st ai ty i cousequme o thePERMIT ISSUANCE 10.00
granit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
tgnelure of licanf C r Dal
OFFICE COPY
1 -
APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS 1116 4
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S - PLAN CHECK VALIDATION
NAM ) QTY. ELECTRIC PERMIT FEE 1
Py ' "� )
COPfRLUfTOR S - UTLETS-SWITCHES-RECEP 10.00/1.00
ME 1
LIC.NOLI 1W
LIGHTING FIXTURES 10.00/1.00
f,ONTRACTO 's APPLIANCES-RESIDENTIAL 4.00
EBS
PHD PANELS 10.00 DATE OF APPLICATION
ARCNrtsc PANELS (OVER 200 AMP) ,20.00 PLAN CHECK FEE P.C.NO,
D
EN
Llc.No. SIGNS TRANS. 3.00
ARCH.ORENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER O POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH. /f/f1 `
ADDRESS �\
SERVICE CHANGE 20.00 ` /�-7
wO O LICENSED CONTRACTORS DECLARATION l
<u u -I hereby affirm that I am licensed under provisions of Chapter 9 /uANCE DATE
y <n (Commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H N i Professions Co .d m license is in full to El El z O m- License Cl ss s Lic.Numb
o � Contractor]
a x BUILD NG PERMIT
¢ w ¢ OWNER-BUILDER UECLARA'fION INFORMATION
w LL I hereby affirm that 1 am exempt from the Contractor's License MISC.- R TOORD
VALUATION $/FT.
.. 0¢ Law l'or the following reason.(Sec.7031.5;Businessland Professions PERMIT ISSU 10.00
NJ Code:Any city orcounty which requires a permit to constrUCLalter,
w improve,demolish,or repair an Slmclur¢,poor to its issuance,also EL C.C QTR. L.,I/C.NO. ELEC.
¢ ¢ a O r pY ��Cl�
o LL
requires the applicant for such permit to file a Signed statement that TOTAL J PERMIT TO
u w es he is licensed pursuant to the provisions of the Contractor's License
z i
Law(Chapter 9(Commencing with Section 7000)of Division 3 ofthe LG
¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
P x O
m $ the basis for the alleged exemption.Any violation of Section STORIES TYPE CONSTR.malty
by any applicant fora permit subjects S500).licamwacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
�..
of not marc owner
Ove the prop dollars(55 employees
O 1,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 sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00 '
Code:The Contractor's License Law does not apply to an owner of
property who builds or impmves thereon,and who does such work FIXTURES-PER TRAP 5.00 BO.FT.FLOOfl AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mu GAS-EA.SVSTEM-i INC.4OUTLETS 6.00
enare not intended or offered for sale.If,Imweeer,the building
or improvement is'Old within one year of Completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
in IdeT will have the burden of proving that he did not build or im- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 El El 11 13 El
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-OV ER 5(EA.) 1.00
Contracts fol such project with a contractoo s)licensed pursuant to
the Contractor' License Law SEWER-SAN ITARV-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lamexempt ec. .B.&P.C.nor this WATER HEATER W/VENT 6.00
reawn
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSAi'ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure. ` ZONING ENG.SITE NO.
or a certificate of Workers'Co-3 Ins ra e,or certified
copy thereof(See 3800,Lab.0
Policy No. Company '�-Q(_Y�I-�-
❑ Certifies.-_'opy is hereby fur nis ed FIRE SPRINK ENERGYTYO ^
Ic iq�("dW-With the t y`�•cI dnision. MISC.- REFER TO ORD.
Z ZO App(cunt /S( p0 1'� f� / f f hf Y ❑ N❑ Y ❑ N❑
F-- yPERMIT ISSUANCE 10.00 FLOOD ZONE . A.L.U.C.
CC - CERTIFICATE OF IiXEMPI'[ON FROM WORKERS'
LU > COMPENSATION INSURANCE PLO.CONTR. LIC.NO. PLG. Y❑ N❑ Y Q N❑
C O (This section need not be completed if the permit is for one TOTAL
Z htmdreddoIImrS(S100)mIC..)
U O 1 certify that in the performance of the work I'or which this per- DTV. MECHANICAL PERMIT ` FEE FEE SUMMARY
LL H mil is issued,1 shall not employ any person in any manner so as to
' Q W
become^ 'ems the Workers'Compensation Laws of California.
'• BUILDING
Date- T" ALTER OR ADD TO MECH. 5.00
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F" Z emption,you should become subject to the Warkeri 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 10,00)C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 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 AddHEATI NG UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
ress
I certify that l have read- Lsapll'�rznd State that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county BOILER-COIL)H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,1100 BTU)SEE FEE SCH. MECHANICAL
' \ a -mentorroperly for inspection purposes.
(WV
ave, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cuperamiilies, d is nd expenses which CONST.TAX
m ecrue ago st ai ty i cousequme o thePERMIT ISSUANCE 10.00
granit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
tgnelure of licanf C r Dal
OFFICE COPY
1 -