9519 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
T ADDRE s^ /�
/V � BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OW ER'S PLAN CHECK VALIDATION
ME `. OTY. ELECTRIC PERMIT FEE
NON EaIacTos ' !SseUTLETS-SWITCHES-RECEP 10.00/1.00
_ µ/Jc.Na.�1? LIGHTING FIXTURES 10.00/1.00
rONTRACTORa APPLIANCES-RESIDENTIAL 4.00
ADORR151 /,r I /']/ J
06( _ 64 PRO N{�j -�( PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDREss ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
Zip rrEMP.METER OR POLE INS. 20.00
APPLICANTS• MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a U I hereby affirnl that 1 ren licensed Under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
Q H BLDG. ELECT. PLG. MECH.
H.N z Professions Code.and my license is in full LORD drf'e ❑ ❑ ❑ ❑
0 o-m Licens las Lie.Numb
9 Date Contractor
a y EuM BUILDING PERMIT
¢ a OWNER-R-BUILDER DECLARATION
BE
o a U INFORMATION
w 3 _ - I hereby affirm that I .m exempt from the Contractor's License MISC.- REFER TO ORD
FULLoto Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city or county which requires a pennit to mnstruct,alter,
aca ¢ o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
a¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
F.
m" he is licensed pursuant to the provisions of the Contractor's Licenseg
r z r
Law(Chapter 9(commencing with Section 7000)of0ivision 3 ofthe /OIL
a Business and Professions Code)or that he is exempt therefrom and QTY- PLUMBING PERMIT FEE
¢ r c the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
C. by by any apphemil for a pcmtitsubjCct,the applimul it,.cRil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred doll.rs($500).):
❑ 1,as owner of the property.Or my employees with wages as BACK F LOW PROTECT. DEV ICE 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 docs such work FIXTURES-PER TRAP 5.00 SO.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-I INC.4 OUTLETS 6.00
or ireproventent is sold within onc,yea(of completion,the owner- GAS EASYSTEM OVER 4 (EA) 200
builder will have the burden of'.proving that he did not huild or ire - . - . .
- BUILDING USE
prove for purpose ofsale.). - INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ 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(EA.) 1.00
contracts t'orsuch projects with a contractods)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I ant excerpt under Sec. ,li.&P.C.for Otis WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK F-RS'CONIPENS,Cf1ON DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a ce IficatC of consent io sel&insure,
or a cert il'ic.te of Workers'Corel nsation Insurance,or a certified ZONING ENG.SITE NO.
mpg thcrenl'IScc.3800,Lan
Policy No. C rpa y
❑ Certified copy) Ire v RheJ' FIRE SPRINK ENERGY T 2
z Z ❑ Certified cop is th the city inspection division. MISC.- REFER TO ORD.
F Q APPlicam Y ❑ No v ❑ N❑
D CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 Q FLOOD ZONE A.L.U.C.
LU � COMPENS4subjec
URA,NC'
PLG.CONTE. LIC.NO. PLG.
CL Z ('Phis seclion need not bd if (lie perruit is for one TOTAL Y❑ NE] Y ❑ N❑
U O hundred dollars IS 100)Or Ica
I certify that in the per Himhe r which this per. CITY.
MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is'ss I it I shall not empn y manner so as
U bccot s ) I a Worke O to
ED Date '� ` Appiican BUILDING
} W NOTICE TO APPLICANT: ing this Certificate of Ex- ALTER OR ADD TO MECH. 5,00
F Z_ emption,you should become he Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit strait be deemed revoked AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10)000C.F.M.) 6.00 SEISMIC FEE
I hereby.affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the perfdnnance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.T HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender'sAJdress ELECTRIC
I certify that 1 have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
• information is correct, I agree to comply with all city and county COME(3 H.P. 6PLUMBING / GI••G
ordinances and state laws relating to building construction, and BOILER- .P.or 100,000 B.T.U. .00 yr
hereby authorue representatives of this city to enter upon the BOILER-COMP(Over 100,080 BTU)SEE FEE SCH. MECHANICAL
above-me net property for inspection purposes.
(We iec to save ' de 'ly and keep harmless the City of MISC.- REFER TO ORD.
Caper against Jiti ,Ise 1ments, costs and expenses which CONST.TAX
may ry wa acct st mid City in on qucncc UC the - PERMIT ISSUANCE 10.00
gran t'Iltis er ^/ MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
t o i an onlractor Date
INSPECTOR COPY