4278 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENT]FICATI ON PERMIT NUMBER
BUILDING L APPLICATION & PERMIT A O
A004FSSel 9�I lam 1 I'T_ BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 4 0
OWNER'S -- - - - -- -- ---- - �' - - - PLAN CHECK VALIDATION
NAMEbLt rig I u 53. q OTY. ELECTRIC PERMIT FEE '
48 ONE
CONTRACTOR'S
NAME (('' OUTLETS-SWITCHES-RECEP 5.00/1.00
ftPN LIC.NO.30DL7LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S
I
Aoo�ss PPLIANCES-RESIDENTIAL ' 4.00 '�I lb Rai I WN AVC9NNE 3%JDPANELS 5.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE
OR SIGNS 6.00
ENGINEER -
Llc.No. SIGNS TRANS: 3.00
AARCH.OR DDRESS ENG' SPECIAL CIRCUIT 5,00 PERMIT VALIDATION'
ZIP TEMP.METER OR POLE INS. 15.00
APPLI
ANT'S
S60-6' w" Av MOTORS SEE FEE SCH:
SERVICE CHANGE , 10.00 /
wO O LICENSED 'ONTRACTORS DECLARATION _
Fi W I hereby affirm that I am licensed under provisions of Chapter I) /,� Jf3 ISSUANCE DATE
a o. (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F o i Professions C.&da license is in full for, n e 1'e'[
z o
c,' - License Class_(<^J� Lie,NumberEl
o y rw Date wk4Contractor-�
"- win NG) BUILDING PERMIT
¢ ¢ w OWNC -BUILDER DECLARATION INFORMATION -
wo A E.U I hereby affirm that I am exempt from the Contrador's License MISC.- REFER TO ORD
LL IL H VALUATION $/FT.
au Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,alter, 'r
Ka, ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. '
o ¢ requires the applicant for such permit to file a signed statement that , TOTAL
a. w m" he is licensed pursuant to the provisions of the Contractor's License PfE�RMIT TO
Li Law(Chapter 9(commencing with Section 7000)ofDivision 3 of Ole
F4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
te r $ the basis for the alleged exemption,Any violation of Section 7031.5 STORIES TYPE CONSTR.
d ; - by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2,00 OCC.GROUP RES.ONITS
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. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 aQ FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
mentsarenutintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- . .RES IND CON PB Omer
prove for purpose of sale I. INDUSTRIAL WASTE INTER. 20.00
❑ 1,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. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor S License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA-) 1.00
contracts for such projects with a contractods)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCELLING.
❑ lam exempt under Sec. ,B.&P.C.lin this WATER HEATER W/VENT 4.00 -
reason
Date Owner WATER SYSTEM 4.00 , ACC.DATE ALC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00 '
I hereby affirm that I have a certificate of consent to self-insure.
or a certificate of Workers'Compensation Insurance,or it certified ZONING ENG.SITE NO.
copy[hcrep[L Fk5 ',(�80Q Luny J F. CbMF of
Policy ere ,L.I, f EC
O Certified copy is hereby famished FIRE SPRINK ENERGY T-24
Z Z CertiO N I��yAAh� ty i s e'ti n division. -
O Applicant ' I�N�. -�:� MISC.- REFER TO ORD. Y� N� Y ❑ N❑
Hy PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.c.
Lu > CERTIFICATE OF EXEMPTION FROM WORKERS'
W COMPENSATION INSURANCE PLG.CONTR. LIC.N0. PLG.
0. O (This Section need not be completed if the permit is for one TOTAL Y C] N0 Y NC_
0Z hundred dollars(S100)or less.)
0 O 1 certify that in the performance or the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
eA
ED Date Applicant ALTER OR ADO TO MECH. 4.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
f" ? emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
L.1 such provisions or(his permit shall be deemed revoked, AIR HANDLING UNIT.(TO 10,000C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE 4
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ,CJ. HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(O VER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING "
ordinances and slate laws relating to building construction, and BOILER-OOMP(3 H:P.or 100,0008.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
%ce to save, i comity and keep harmless the City of MISC..- - REFER TO ORD.
Cugainstli ilio ,judgments, costs and expenses which CONST.TAX
ma ay ac rue g2init said City in consequence.of the PERMIT ISSUANCE 3.00
gra1 perms MECH.CONT, LIC.N0. MECH.
TOTAL TOTAL 511
Signetu enf Applicant Cnnfmdor Dnte
OFFICE COPY '