17484 APPLICANT TO FILL IN INFORMATION WITHIN RED, LINES - USE BALL POINT PEN ONLY '
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
Sc APPLICATION & PERMIT
ADDRESS 17484
ADDRESS
10,45-M Al, 1104AIZA 06/4 BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWN PLAN CHECK VALIDATION
N/ OTY. ELECTRIC PERMIT FEE
C NTRA TO 'S 0
e :F ( Na a OUTLETS-SWITCHES-RECEP 10.00/1.00 '
_ LIC.ND. LIGHTING FIXTURES 10,00/1.00 -
CONTRACTORS
ADDRESSPPLIANCES-RESIDENTIAL 4.00
� PNONE4y7-D/' PANELS - 10.00 DATE OF APPLICATION-
otiN TE - PANELS (OVER 20CT 0 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER .•
- TIC.No. SIGNS TRANS. 3,00
Age"ASS
ge"OR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
- ZIP EMP.METER OR POLE INS. 20.00 �/ ,� Z�� 6
APPLICANT'S 1
ADDRESS .MOTORS SEE FEE SCH. C
117 Sa 10 SERVI CECHANGE 20.00
-00 LICENSED CONTRACTORS DECL �_&
ARATION ' all Yl . c
a U U 1 hereby affirm that I am licensed under provisions of Chapter PAD, ISSUANCE DATE
H Q udai (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H z Professions Cl a m icense is in full fore d e t. r
0 i m o License Cl ss - Con Number_'_
HwH J Datc-t;„�q-g Cnntmctnr_ -?.� BUILDINGPERMIT
ArK
a 2¢ u -F C/' OWNER-BUILDER DECLARATIU 1I -
is ,u N I hereby uflinn that I am exempt from the Contractor's License
MISC.- IJ RB mfbRD INFORMATION .
'a u O ¢. Law for the following reason.(Sec.703 L5,Bus w.,lnd Professions VALUATION
- PERMIT ISSUANCE -40.00
Code Any city or County which requires a permit to cumtrral,alter,
QS f p improve,demolish,m repair any structure.prior to its issuance,also ELEC.CONTR., LIC.NO.
requires the applicant for such permit to file a signed statement thatrillclir-
Iil
w PER IT TO
$ he is licensed pursuant to the provisions of the Contractor's License Clk
tiQm Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe l/9\
5 i o Business and Professions Code)or that be is exempt therefrom and CITY. PLUMBING PERMIT l E
X r the basis for the alleged exemption.Any violation of Section 7031.5 / STORIES TYPE CONSTR.
i ; ,.. by any applicant for a permit subjects the applicant to a civil penalty
of art more than five hundred dollars($500)): ALTER-DRAIN&VENT-WER (EA.) 0
O 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVIATCE 45,.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 aLowner of -
�. property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-l1NC.40UTLETS 6.00
}� or improvement is sold within one year of Completion, the owner- -
'f W builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
V7�1.• RES IND CON PB ONer
prove for purpose of sale.).
❑ d as owner of the property,he exclusively,7044,1Bu with INDUSTRIAL WASTE INTER. 30.00 El ❑ ❑ 0 ❑
licensed contractors to Construct the protect(Sec, does,of apply LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The who
builds o License s th docs not apply
_� to tr owner of property who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00 ^
Contracts for such projects with a contraclorf s)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM 200ft/1 .00 TRACT NO. PARCEL NO,
r ❑ Ism exempt under Sec. ,B.&P.C.for this WATER HEAATEEW/VEN6
R W/VENT 6.00
reason
Owner Date WATER SYSTEM 5,00
ACC.DATE ACC,FILE NO.
WORKIiRS'COMPISNSATION DECLARATION WATER TREATING EQUIP. 5,00
I hereby affirm that I have a c,niflome If coaxer to se If...S'ne,
or a Certificate of Workers'Co,P�� ' tion 11 u4rc a ee ified ZONING ENG.SITE N0,
copy thereof(Sc,.3800,Lub.q)`;Jgj `�
Policy No. Compan,r�._�r_ �`lU(
(] ❑ Certif npy is herebyiu Isht -7 FIRESPRINK. ENERGY T-24
Z Z ❑ Certif p K I d t "Aof
'v" n.
FO_ Applicant `/pUCJpp)�) CCILg'� _ � MISC.- REFER TO ORD. y NY ❑ NC]
C JKTI rICA'kUlz 17(-. I'f( . PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.0 c.
.W > COMPENSATION INSURANCE PLO.CONTR. LIC.NO. PLG,
Cl (This section need not be completed if the permit is for ane TOTAL Y[D IN Y❑ IN
hundred dollars($100)or less.)
U O I certify that in the performance of the work for which thi,per- OTY MECHANICAL PERMIT' FEE FEE SUMMARY
LL F mit is issued,1 shall not employ any person in any runner so as to
Q W become subject to the Workers'Compensation Laws of California.
d Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ to NOTICE TO APPLICANT: It.alter making this Certificate of I's-
F ? emPtion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK.
provisions of the Labor Code; you must forthwi0l comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C-F.M.) 4.00
CONS'T'RUCTION 1.I7NDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 the perlimnance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 6.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U,)9.50
Lender's Address ELECTRIC
I certify that l hove read this application and stale that the above VENTILATION FAN (SINGLE) 4.00 dQ
^ infornmtion is correct. I agree to comply with all city and county BOILER-COMP(3 H.P,or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and slate laws relating to building construction, and
hereby authorize representatives of This city es enter upon the BOILER-CO P 10 100,000 BTU)SEE FEE SCH. MECHANICAL 3 I,
above-menlioneA property for inspection purposes.
We) agree to save, indemnify and keep harmless the City of MISC.- .4� R TO ORD.
n tiro against liabilities,judgments, Costs and expenses which - CONST.TAX
m in any way , e gai st said City in conse
udue cc of the PERMIT I SUANCE 10.00 (• d
ting of This p L MECH.CON LIC.N0. MECH.
CY // E �TAL36I.J--U TOTAL 2t).9
Signature o pphcant/ ontractor Date
OFFICE COPY