11162 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICA PERMIT NUMBER
BUILDING APPLICATION & PE ^
AooREsi
D x IU� BUILDING - ELECTRICAL-PLUMBING-MECHANICAL G
OWNERS - l PLAN CHECK VALIDATION
NAME a Cls ELECTRIC PERMIT FEE
-V vNONE
RAcroR's
NAMEUTLETS-SWITCHES-RECEP 10.00/1.00 U --'
uc.NO. LIGHTING FIXTURES 10.00/1.00
ADDREScrons APPLIANCES-RESIDENTIAL 4.00
CONTRA
PHONE PANELS 10.00 DATE OF APPLICATION
ancNrtscT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
oR
ENGINEER
uc.rvo. SIGNS TRANS. 3.00 "
ADDRESS eNc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION 1
ZIP TEMP.METER OR POLE INS. 20.00 - y✓
APPLICANrS
ADDRESS
MOTORS SEE FEE SCH. /�'(,.JJ�•
oREss
SERVICE CHANGE 20.00
,02
oO LICENSED CONTRACTORS DECLARATION
aL,U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y Q w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r 7 z Professions Code,and my license is in full force and effect. ❑ El Z=o License Class Lia Number
Date Contractor
1, ) BUILDING PERMIT
a wu OWNER-BUILDER DECLARATION MISC.- OORD INFORMATION
wg-a.y 1 hereby ofDrn that I am exempt brain the Contractor's License VALUATION $/FT.
wD ¢ Law far the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE
fw� Z Code:Any city or county which requiresapermit to construct,alter,
re ¢ Q O improve,demolish,or repair any structure,prior to its issuance,also E EC.CO TR. LIC.NO. 1 LEC. (�.4e
n x m u requires the applicant for such permit to file a signed statement that, Y G VIL
TOTAL V -- PERMIT TO
w _ he is licensed pursuant to the provisions of the Contractor's License
Fit Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe 1i7 s�--/yyT
¢ Business and Professions Code)or than he is exempt therefrom and OTY. PLUMBING PERMIT FEE
pro the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d3 � by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(3500).):
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00 OCC,GROUP RES.UNITS
their sole compensation,will do the work,and(he structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 5.00
Code:The Contractor's License Law does not apply to an owner a1'
Property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SQ FL FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
meats are not intended or offered for sale.If,however,file building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
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 lie did not build or im- BUILDING USE
prove for purpose of sale.). - INDUSTRIAL WASTE INTER. 30.00 RE5 IND CON PB Doer
❑ 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 ofroperly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts u 1 projectswith tractor(sl licensed pursuant to
is se L
SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the C actor's iaw-
I am exe n Sec. ,B.&P.C.fr Be, WATER HEATER W/VENT 6.00
reason _
Owner_ Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WO iRs'COMPI>N N DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy Ihereof(See.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD, y❑ N[] y ❑ N❑
O Applicant
Hy PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.L.
LU > CERTIFICATE OF EXEMPTION FROM WORKERS'
LU _ MPIiNSAT10N INSURANCE PLG.CONTR. LIC.NO. PLG.
M 0 (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
0 Z hundred dollars(S 100)or Icss.)
U 0 1 certify that in the performance of he work for which this per- OTY. MECHANICAL IT FEE FEE SUMMARY
F- mit is issued,I shall not employ any n in any manner so as to f.,.
LL U becom s bject to the Workers'Compe s o f Ifornia. ,. '
i UmeAPPlicam ALTER OR ADD TOM H. 5.00 BUILDING
} to NOTICI, TO APPLICANT: If,aft r in ihi r ficatc of Ex-
F Z emption,you should become subject t the Wor s' 'ompenmtian APPLIANCEPLAN 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 1 ® . 4.00
CONSTRUCPION LENDING AGENCY AIR HANDLING UNIT(OVER 64000.EM.16.00 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. HEATING UNIT(TO 100,000 B.T.U.) 6.00 MICROFILM
3097,Civ.C.). -r-
Lender's Name
Lender's Name NH EATI NG U N IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC S-OL
I certify that i have read this application and staler that the above VENTILATION FAN (SINGLE) 4.00
k information is correct. I agree to comply with all city and countyPLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.1 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 STU)SEE FEESCH. MECHANICAL
above enlioned property far inspect ion purposes.
(W agree to save, i y and keep harmless the City of MISC.- REFER TO ORD.
Cape na ag nst liabilities,ju mems, costs and expens s which PERMIT ISSUANCE 10.00 (� CONST.TAX
may ,any ay accrue ago' t id'City in consequen of the
gran et iL MECH.CONT. LIC.NO. TOTALK
�� _ TOTAL5Z R
\( IgA ur f pp icant/Cr roc r Dat
/ OFFICE COPY