9109'+ APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
RDILDINc APPLICATION & PERMIT ^w ��
ADDRESSc7 r y I
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
D 's PLAN CHECK VALIDATION
NAME
� QTY. ELECTRIC PERMIT FEE
HONE
mgmraAciluq,y, �s"k yU�� UTLETS-SWITCHES-RECEP 10.00/1.00
�/S uc.ND. L IGH TI NG FIXTURES 10.00/1.00
(10174THAtTORs
ADDRESS APPLIANCES-RESIDENTIAL _ 4.00
-�
PHONE PANELS 10.00 DATE OF APPLICATION
OR ( ECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LC.No. SIGNS TRANS. 3.00
nooess ENc' SPECIAL CIRCUIT 5.00 ' PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
00 LICENSED CONT RACTORS DECLARATION TEMP.POLE 30.00 / 0
< i w PLG. MECH.
I hereby affirm that I am licensed under provisions of Chaplc,9 BLDGELECT.ISSUANCE DATE
m a y (romnu•nnng with Section 7000)of Division 3 of the Business and .
H m z Professions Co and my license is in full for a r L ❑ ❑ ❑ ❑
z o m - License Cla Lic.Numbcr S`
Es L w Uate---_��Contraclor- --
st m E '/ - BUILDING PERMIT
o i u OWNER-BUILDER DECLARATION INFORMATION
wg; u w 1 hereby affirm that 1 am exempt from'the Contractor's License MISC.- REFER TO ORD
Fuoj Law forthe following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION SIFT.
Code:Any city or county which requires a permit to constructyalter, C/
so ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. o U b
so
O or edetates the applicant for Such permit to file a Signed Statement that TOTAL
w $ m he is licensed pursuant to the provisions ohthe Contmctor's License PERMIT TO
> I-aw(Chapter 9(commeneing with Section 7000)of Division 3 of the T
fi o Business and Professions Coda or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE SK LP c /
H o the basis lot the alleged exemption.Any violation of Section 7031.5 ST0 IES TYPE CONSTR.
a3 � by any applicant for a permit subjects the applicant tea civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(S500L)
❑ 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 sal,(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:"fhe Contractor's License(Caw does not apply to;in owner of '
property who builds or impro"vcs thereon,and who docs such work FIXTURES-PER TRAP 5.00 so.Pr.FLOOR AREA TOTALACREAGE
.cutsforthrough.Iintnde ownemployees,for sale.
if,edthat Such inmrove GAS-EA.SYSTEM-1 6.00
menus um not uncoiled or offered for sale.If,however,the building _
or improvement is sold within one year of completion, .
the owner- GAS-EA.SYSTEM-OVER'4 (EA) 2.00
builder will have the burden of proving that he did not build or im. BUILDING USE
prove for purpose of rale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ d as owner of the property,he exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed cuionsCo s : construct the project La 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License s th docs.an apply _
to contracts
owner of property who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00 -
theCotsctor'shcene ts Lwithaeontractotsl licensed pursuant SEWER-SANITARY-STORM EA.200tt/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.Ior this WATER HEATER W/VENT 6.00
reason
Owner Dade WATER SYSTEM 5.00 ACC.DATE ACC,FILE No.
WORKS RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby allirm that I have a certifiers,of consent to self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.L
Policy No. Company_ Ile
O ❑ CcrtiliCd CO yds hcmby fur sh FIRESPRINK ENERGYT-24
Z Z ❑ Certified � �,fy is fled w 1 ly I cion 'vi.�II MISC.- REFER TO ORD.
p Applicant _ cl Y ❑ N❑ Y ❑ N❑
CC rn f PERMIT ISSUANCE 10.00
- CIiRI'Ib CATC:OF li%li\IPTION FROM WORK ERS' FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
0. 0 \ (This section need not be completed if the permit is for one -- � TOTAL Y❑ N❑ Y E] No
UO hundred da l ln�(S 100)or less.) -
Hcertify that in the performance of the work for which This per- i FEE SUMMARY
LL H mit is issued,I shall not employ any person in:cry none,so as to QTY. MECHANICAL PERMIT FEE
O become subject to the Workers Compensation laws of Califomia.
LU Date Applicant - A LTER,OR ADD TO MECH. j 5.00 BUILDING 0
} 0NOTICE TO APPLICANT: If,after making this Certificate of Ex- -
� 2 coalition,you should become subject to the Workers'Compensation APPLIANCE-—' 5.00 PLAN`CHECK O
provisions of the Labor Code, you must forthwith comply with FEE Ct
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
1 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE a"b
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
�fie performance of the work for which this permit is issued(Sec. MICROFILM
097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
.Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lenders Address ELECTRIC
:-
I ¢vtli thrt l have readthisapplication and ammthat a d county VENTILATION FAN (SINGLE) 4.00
• ordinances n correct 1 s agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
1 ordinances and state laws relating to building construction,upon
and
hereby authentic representatives of this city es corer upon the BOILER-COMP(Over 100,000BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes. '
(We) agree to save, indemnif kec rmless the City MISC.- REFER TO ORD.
Caperti ins, liabilities,j gm Sts a d expenses PERMIT ISSUANCE 10.00 CONST.TAX--
may i any ay acerae ag nst id City in c nseyuence tm
gmnY hg U his permit. '!� MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL a 9U
Sign fApp leant/Contractor Uat ,
INSPECTOR COPY _
__ 1