12000 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
BU I LDING PROJECT I DENTIFICATI ON APPLICATION & PERMIT
ADDRESS
AOovass=XMI7424 Heatherwood BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 12000 OO0
OWNER'S PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
M.A. Silva 253-1725
PHONE
CONTRACTORS I OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
Atlas Heating LIC.NO.465266 ILIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00
ADORE 5 -
f55 Commercial St.RDNE 739-0516PANELS 10.00 DATE OF APPLICATION
PLAN CHECK FEE P.C.NO.
ARCHITECT PANELS (OVER 200 AMP) 20,00
O
ENGINEER
LIC.rvo. SIGNS TRANS. 3.00 ,
ARCH,OR ENaSPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 20.00 W
Ars MOTORS SEE FEE SCH.
ADDRESSDDRESS
SERVICE CHANGE 20.00
O o LICENSED CONTRACTORS DECLARATION /d/
a v U I hereby affirm that I am licensed under provisions of Chapter 9 - ISSUA CE DATE
HQa (Commencing with Section 7000)of Division.3 of the Business and BLDG. ELECT. PLG. MECH.
H D i Professions CQJ421 my license is in full to c e f ct ❑ 1:1 ❑-
2 0,� Lice n Aja Lic.Number as�
O Date U7Conlmctor
5 Y BUILDING PERMIT
2 2 w u OWNER-BUILDER DECLARATION INFORMATION
K;LL I- I herebyaffirm that I am exempt from the Contractor's License MISC:- REFER TO ORD
VALUATION $/FT.
FuOJ Law forthe nycitllorcountywhichecJ031.a permit to construct,
PERMIT ISSUANCE 10.00
Code:Any city or county which requirese permit to construct,alter,
2 ¢< improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
i - DLL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w $ he is licensed pursuant to the provisions of the Contractor's License //
Ia Law(Chapter 9(commencing with Section 7000)of Division 3 of the , /0
i i c Business and Professions Code)or that he is exempt therefrom and OTY.II
PLUMBING PERMIT FEE
H the basis for the alleged exemption.Any violation of Section 7031.$ STORIES TYPE CONSTR.
i by any applicant for a permit subjects the applicant to a civil penalty gLTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ 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 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 does such work FIXTURES-PER TRAP 5.00 sO.FT.FLOOR AREA TOTAL ACREAGE '
himself or through his own employees,Provided that such improve- GAS-EA.SYSTEM-1 INCA OUTLETS 6.00
ments are not intended 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 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ [,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(hereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contraclods)licensed pursuant to
the Contractor's License Law, SEWER-SAN ITAR V-STORM EA.200ft/10.00 TRACT NO. PARCEL N0.
❑ I am exempt under Sec.-.BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dote - WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereat 0,}�."
PolicAllied Pacific
y ere Y
Q [l, Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z Cerlifigi .isAdts's�iylj}Ie city inspection division. RD.
-v MISC.- REFER TO OY E] N Y ❑ N
❑ ❑
H - Applicant PERMIT ISSUANCE 10.00 FLOOOZONE A.L.U.C.
Lo CERT'I FICATE OF Ii XEMPTION FROM WORKERS'
LU _ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. V❑ N❑ Y ❑ N E]0. Cl (This section need not be completed if the permit is for one TOTAL
7) Z hundred dollars($100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL f mit is issued,I shall not employ any person in any manner so as to _ a4..
O O become subject to the Workers'Compensation Laws of California. _
Dale Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ r�i) NOTICE TO APPLICANT: If,after making this Certificate of Ex-
Z 4mption,you should become subject to the Worken'Compensation APPLIANCE (1(' P JtIHVI5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with AIR HANDLING UNIT(TO 10 FEE
U such provisions or this permit shall be deemed revoked. A000.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT OV,ER10p_DC:F.lii 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for .EXHAUST HOOD(WI DUCT) 5.00
the performance of the work for which this permit is issued(Sec.
3097,performance
. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
_
Lender's Name HEATING UN It(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
/ I certify that I hove read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county gO1LER•COMP13 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the g01LER-COMP(Over 10 ,000 TUI SEE FEE SCM. MECHANICAL /� •
above-mentioned property for inspection purposes.
- (We) agree to save, indemnify and keep harmless the City of MISC.- I( F To ORD.
Clipe mo against liabilities,judgments, costs and expenses which' CONST.TAX
ay -Ony way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 /Ori
goer ngof this permit. MECH.CONT. LIC.NO. MECH.
m _ ��_ a a[/ TOTAL TOTAL
SignaNre o(Applicanl/QC omm Uale v^' OD
0 _ - OFFICE COPY 1
:1 -