18748 r
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 1 8740p
ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
NER'S PLAN CHECK VALIDATION
E40
TY. ELECTRIC PERMIT FEE
FHDNI: - . �� 7.Z,. D
/ vrnAcroRs OUTLETS 10.00/1.00
AME �y
LIGHTING FIXTURES 10.00/1.00
CDNTR TORS PPLIANCES-RESIDENTIAL 4.00
aflA
,a 41z.R PANELS 10.00 DATE OF APPLICATION `
ARCHrTECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
Eis.av
�LC.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADD S /p..p� SPECIAL CIRCUIT 5.00 Q
it EMP. METER OR POLE INS. 20.00 ( b
APPLICANT rs/
ADD9S 0/� 4/
/Y� MOTORS SEE FEE SCH.
SERVICE CHANGE PARD 20.00 II••
w o o LICENSED CONTRACTORS DECLARATION v4b Y ✓LL-(
a u I hereby affirm that I am licensed under provisions of Chapter Y I IINI{ 03 I:J:1J ISSUANCE DATE
y Q w tconn.emang with Section 7000)of Division 3 of the Business ynJ BLDG. ELECT. PLG. MECH.
F vi z Pr01'eseions Code,and ,y license ix in lull for Wt'1 9 'y, ❑ ❑
o w- License Class Leis Number- ( IMY�I
o y 5 ,°a Date
Contract r I,(��n� 1 rtF^O.ft100
1e ¢ a DER DECLARA'1'I``0�1111111,,'1; \ BUILDING PERMIT
Et ISC.- REFER TO ORD INFORMATION
ww 1 hereby affirm that I am exempt lion the C,c,s,n to,o License VALUATION
F u O ¢
Law for lire following reason.(Sec.7031.5,Business and Pmfessims R 1 ANCE 10.00 .QD Is-,,,206
�O�O
ym� Code:Any city or county which reyuiresa permit tuconstrucl,alter.
¢ Q 2 improve.demolish,or repair any struClurC.prior to i15 ismmnre,also C LIC.NQ ELEC. rnpt
-o LL requires the applicant for such permit to file a signed statement that TOTAL 6 �V PERMIT TO
u w m he is licensed pursuant to the pmviions of lire Contractor's License
Uzi Law(Chapler9(commencing with Section 7000)of Division3oflhc
¢ Business and Professions Codel or that he is exempt Iherufr m and PL PERMIT FEE
¢r0 the basis for the alleged exemption.Any violation of Section 31.5 STORIES TVP CONSTR.
by any applicant for a permit subjects the applicant loacivil p nahy qt. R-DR IN E T-WATER (EA.) 5.00
of not more than five Imndred dollars 15500).1:
❑ 1,as. of the property,or my employees with w' ' BA' F PR CT. DEVICE 4.00
their sole compensation,will do the work,and the structur is si I OCC.GROUP RES.UNITS
intended or Offered for sale (Sac. 7044. Business and Pr Gssi D AI S- R,ROOF,AREA,COND. 5.00
Code:The Contractor's License Co.docs not apply to an owne of
property who builds or improves Ihercon,and who does such rk U -PER,TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that so i ve-
meatsarenotintendedoroflereJforsale.If,however.the wilding GA E .SYSTEM-11NC.40UTLET$ 6.00
or improvement is sold within one year of comphilion.the owner- .E .SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did Trot build or im- RES IND CON PB Ohnat
prove For purpose of sdc.). I NDUSTR I A L W ASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors m construct the project(Sec.7044.Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:'1 he Contractor's License Law dues not apply
1.an owner of property who builds or improves Haire..,and who LAWN SPRINKLERS OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
the❑Contractors License Law. _ SEWER-SANITARY-STORM EA.200ft/10.00 TRACT No. PARCEL No.
I are exempt order Sec. ,B.&KC.I.,llin, WATER HEATER W/VENT 6.00
reason
Owner [)ale WATER SYSTEM 5.00 ACG DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
1 herebym(Urm that I have a certillcale ofconsent to self-insure, ZONING ENG.SITE NO.
or u cettil'icale of Workcrs'Compensation Insurance,Ora cerlifieJ-
copy mere �J}j 00,Lab.QL Q•
POlic,Y No. Y.7Company_/{LQ
Q �F Certified copy is hereby furnish d. FIRE SPRINK ENERGY T2
Z ZO xf Certif-d c is fled v'th the city insp clion di inion. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
m CERTIFICA01'1:OF EXEMPT ION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
UJ > COSIPIiNBATION INSURANCE PLG.CONTR. LIC.NO. PLG.
(L 0 I'l his section need not be conplered if Hie peril is for one TOTAL Y❑ N❑ Y ❑ IN
Z) 2 hundred dollars IS 100)or le".)
U O 1 certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEEWMICROFILM
LL 1- not is issued,I shall not employ any person in any manner so as In
0U become subject to the Workers'Compenwlion Laws of California. ��Lu Date Applicant ALTER OR ADD TO MECH. 5.00 4to N'01'ICE TO APPLICANT: If,after making this Certificate of nix-you should become subject to the Wcrkrx'Compensation APPLIANCE 5.00 provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deeined revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00CONST'RUCTION LENDING AGENCY AIRHANDLING UNIT(OVER l0,000C.F.M.) 6.00 Z�1 hcrcby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
me performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00
3097,Civ,C,).
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.19.50 ELECTRIC 6�
Len Jars Address
I certify that l have read this application undsnm n,m the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP IOssr 100,000 BTU)SEE FEE SCH. MECHANICAL
ab.ve-mentioned property for inspection purposes.
(We) agree t. save, indemnify and keep hannlcss the City of MISC.- REFER TO ORD.
upertin0 against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10,00 CONST.TAX,
may i any way neer against silid City in consaluence of the
rzan n oft is anfL a MECH.CONT. LIC.NO. MECH.
16 TOTAL TOTAL
nature of Applican-drLontractcar U c 1
OFFICE COPY