8389 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATI ON PERMIT NUMBER
�( aDILDING APPLICATION & PERMIT
ADORES
` BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 838
OWNER'S PLAN CHECK VALIDATION
AME3^�3 QTY. ELECTRIC PERMIT FEE
PNONE J
CONTRACTOR UTLETS
10.0011.00 Q-�
uC.N LIGHTING FIXTURES 10.00/1.00
ADDRESS TGRS a APPLIANCES-RESIDENTIAL 4.00
9
PR 63n1 PANELS 10.00 DATE OF APPLICATION
HITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
G
ENGINEER
LIC,NO. SIGNS TRANS. 3.00 -
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT s MOTORS SEE FEE SCH.
ADOREss
SERVICE CHANGE 20.00 pr
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE f' 30.00 �' Osl �
a z w I hereby affirm that I am licensed under provisions of Chapter 9 _ ISSUANCE 6/ATE
a, a y (commencing with Section 7000)of Divisio 3 of the Business and BLDG. ELELT. PLG. MECH.
s-N i Professio
an Q my license is in full r c n e(f f " ❑ ❑ ❑ ❑
m O m - Licen Class _\_Lic.Numh
D z I- Date Cant
BUILDING
a x s ni Caper:OQ BUILDING PERMIT
a OWNIi R-BUILDER DIiCLARATION
x o>u INFORMATION ,
X ;u N 1 hereby uffrm that I am exempt from the Contractor's License MISC.- R I R TO ORD _
a- as Law for the following reason. 7031.5,Business and Professions pERM1T ISSUANCE VALUATION E/FT.
fw Code:Anyeity orcounly which requires a permit to construct,alter,
rt or Q O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTH. LIC.NO. EIEC.
a wO LL requires the applicant for such permit to file a Signed statement that TOTAL LJ�.I� PERMIT TO
$ he is licensed pursuant to the provisions of the Contractor's License
rzi
La.(Chapter 9(commencing with Section 7000)crDivision 3 ofthe -
fi c Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
M r $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
s ; - by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(8500).):
❑ 1,as owner or 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 to (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CONO. 5.00
Code:The Contractor's 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 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees•provided that such improve-
ments are not intended or offered for sale.l f,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner
-
.GAS-EASYSTEM OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose oleJ. INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ as owner off tire property,ran exclusively contracting with 1:1 1:1 11
licensedd contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professionsions Code:The Contractor's License Law does not apply
to an owner of property who builds t r hors)licensed
thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
the Contractor's
ctor's h projects with n contractors)licensed pursuam to
I the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exemp[under Sec. ,B.&P.C.lar this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORK ERS'COMPHNSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
-APolicyN
copy thereof(Sea.3 oLab
IY�
Q ❑ Certified
ified copyis ere furnished. FIRE SPRINK ENERGY T24
�/ ❑ Cert to y 11 Ith the city inspection division.
Z'6 1 Apnlicun .�. MISC.- REFER TO ORD. v � N� v ❑ N❑
~ rn PERMIT ISSUANCE 10.00
LuCERTIFICATECOMENSATON INSURANCEFROMORKER$' PLG.CONTR. LIC.NO. PLG, FLOOD ZONE A.L.0 c.
CL0 (This section need not be completed if the permit is for one TOTAL Y F] NE] Y [:] NF]hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per exrsr MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as m `CnYI
O U become subject to the Workers'Compensation Laws of California.
o- Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex.
F 2 emption,you should become subject to the Workers'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=CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER IOPWC.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.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and state that fire above VENTILATION FAN (SINGLE) 4.00
information is correct, I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) IS=
hereby n Drize representatives of this city to enter upon the BOI LER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-m ti cd property for inspection purposes. -
(We) to to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cu o ago ist liabilities,judgments, costs a d expenses which pERMIT:ISSUANCE 10.00 CONST.TAX
ay m y seem 'nst said City in c asequence of the
granbn I this or it MECH.CONT. LIC.NO, MECH.
TOTAL TOTAL
Sign re Ap It , ntmetor Date
OFFICE COPY
r