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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL -PLUMBING - MECHANICAL
PERMIT NUMBER
6001
NOLOING Or TE 0
ADD ss
1.
OWNER'S
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,� "�lAWi' `x �' kJ kseT
OTY: ° LECTRIC PERMIT
E
lA ( rt �i , re 4?a
PLAN CHECK VALIDATI0
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V
"60AMERACDRs
UTLETS- SWITCHES -RECEP 5.00/1.00 3 -
LIGHTING FIXTURES 5.00/1.00
c. N.
C-Dcross
AO` V E 55 I
PPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
J I
DATE OF APPLICATION
ARCluTFCT I
OR
EN C
SIGNS 6 DO
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
AARCH
DDRESS DOING.
��
L4,6zIP
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 15.00
A mANTi
ADDRESS
MOTORS RAUDECH.
SERVICE CHANGE _ 10.00
LICENSED CONT RACTORS DECLARATION
I hereby u111nn that I wr hL"tdwd under pro -ions Of Chapter 9
Icomnlrmcmg with Section '0(101 of Uivisim, I the Businessarid
1, "1leas....¢ Cnde rid my license is in full fo
License Cil�ha - Lic. Numbe
ISSUANCE DATE
I I"'
BLDG. ELECT.
PILO. MECH.
❑
_
Dolt _Contract.
.. -: BUILDINO;PERMIT •-•--�
INFORMATION'
�_
ow. ER-BuaDER .r
hereby uollnn that 1 am exempt ro D t 's essionc
Law for the followingnlyw.che.uires a, mit toe Professions
Code: Any euros coonpair any structure permito nuance,
MISC. - REFER TO ORD
PERMIT ISSUANCE s
6.00
VALUATION
/Q�OOO
$/FT.
ELEC. CONTR. LIC. N0.
TOTAELEC.
TOTAL ( J
also
improve, demolish, or repair any structure, prior to its issuance, also
its
requires the applicant fur such permit t0 file a signed statement that
he Is licensed pursuant to the provisions of the Contractor's License
PERMIT TO
OTY: - PLUMBING PERMIT.' • 5. ".�FEEry-
Law (Chapter9(commencing with Section 7000) of Division 3 of Ilse
liusiu,,, and Profession, Codel or that he is excm pt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5
ANT• I/YAQt7 VC /I'/tr7)
Tp E 6pNSTR.
subjects the applicant lou civil penalty
by my acrethitfor ive hundred
of not more than five hundreJ dollars ISSOOL P,
ALTER-DRAIN-WATER(EA.)4.00
❑ h as owner of the property, or my employees with wages as
(heir sole Compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 2.00
Cr6ROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
intended .r offered for sale (Sec. 7044, Business and Professions
Code: 'fire Contractors License Law does not apply In an owner of
property who builds or improves thereon, and who does such work
h imsell or through his own employees, provided that such improve-
mens are riot intended or offered for sale. If, however, the building
FIXTURES - PER TRAP 4.00
sp1FTpW gyp5p
UI 1. L•y�11111V
TOTAL ACREAGE
GAS - EA. SYSTEM -1INC. 4 OUTLETS 4.00
or improvement is sold w'i thin one year of completion, the owner-
builder will have the burden of proving that he did not build or im-
"rovetor purpose oriole.).
C 1, as owner of the property. am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 1.00
BUILDING USE
RES IND CON PB Doer
❑ ❑ ❑ ❑ Cl
. .
INDUSTRIAL WASTE INTER2000
licensed Contractors to construct the project (Sec. 7044, Business
and Professions Code I he Contractor's License Low does not apply
to in owner of property who builds or improves thereon, and who
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
LAWN SPRINKLERS- OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts for such, projects with a COntract.n s) licensed pursuant l0
it,, Contractor's Lice,,,, Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C. ]or this
reas.11
WATER HEATER W/VENT 4.00
owner Date
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
WORK ERS'COINPENSA'TON DECLARATION
1 hereby affirm that I have a certificate of consent to self -insure,
ur a certificate of Wor ers' Compensation Insurance, or a certified
copy Thereof (Sec 3g , La C.I. j� trs�pyp,�y
PDI, n. m y_ Lt121�
Cetlified c sir I (u I
Cert crit I Ir�1 be city inspection division.
Applicant
ZONING
ENG. SITE NO.
FIRE SPRINK
Y❑ N❑
ENERGY T.24
Y❑ N❑
MISC- REFER TO ORD,
('T '1A jV
MPTION FROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.u,c.
MPE TION INSURANCE
IThis section need not he completed if the permit is for one
PLG. CONTR. LIC. NO.
PLG.
TOTAL
Y ❑ N ❑
Y ❑ N ❑
hundred dollars IS 100) or less.)
I certify that in the performance .f the work for which this per
nil Is issued, I shall not employ any person in any manner so as to
becomesubjecltotheWorkers' Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: If, after making (his Certificate of Ex
c :. - - �. -
- :r - t �,; FE�u
OTY MECHANICAL PERI)
aFEE SUMMARY. "'A,si"
-
BUILDING
[��r
ALTER OR ADO TO MECH. 4,00
APPLIANCE 4.00
PLAN CHECK
FEE
eruption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (TO 10=C.F.M.) 3.00
AIR HANDLING UNIT (OVER 10=11F.M.) 5.00
SEISMIC FEE
7 3c
CONSTRUCTION LENDING AGENCY
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.
3097, Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lenders Name
HEATING UNIT (OVER 100,000 B.T.U.P.50
ELECTRIC
Lenders Add
I certify that I have read this application and stale that the above
VENTILATION FAN (SINGLE) 3.00
information is cos 't. I agree t. m
c ply with all city and county
ordinances and a laws rel to building construction, and
PLUMBING
BOILER -COMP(3 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP (Ower 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby Guth r• scrum of this city to enter upon the
A. ,,ncu ne roperly //mspeaion purposes.
(W& o save. afnnify rid keep harmless the City of
Caper' - stwhati costs and expenses which
may ir sac City in const encu of the
gra g [
/ fi
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 3.00
MECH. CONT. LIC. NO.
MECH."
TOTAL
TOTAL�;1--"
(o/G 31
g r ntractor are
L��Y' v OFFICE COPY