11230 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 11230
ADDRESS
O //9D BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S W( -f/ PLAN CHECK VALIDATION
. NAM � CITU. ELECTRIC PERMIT FEE
C NAME 0Nrflacrofl's UTLETS-SWITCHES-RECEP 10.00/1.00
1�
$-�q-{Z �� Ic.No, y,�.L27� LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
ADDRESS /II �^ [�
01,49 j�3pS/ PANELS 10.00 DATE OF APPLICATION
ARCHITECTPANELS(OVER 200 AMP) 20.08 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.ND. SIGNS TRANS. 3.00
ARCH.OR ENG. 5.00 PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT
ZIP EMP.METER OR POLE INS. 20.00
APPLICANT'S IMOTORS SEE FEE SCH.
ADDRESS /
SERVICE CHANGE 20.00 i U./lfir/{,�O�.aJ
09 LICENSED CONTRACTORS DECLARATIONal Q
tl: u u I hereby Idt'irm that I am licensed under provisions of Chapter 9 UANCE.DATE .
a (commencing with Section 7000)of Division 3 of file Business and
iProfessions Code,and my license is in full force anQ� BLDG. + P/lo, ECH.
z o�.- s'zA C LiLicense Clase.Number _Y ��� ❑ ❑ ❑ ❑
Q w p w Date_e^ fa-,d06 Commctor
rc w a OWNER-BUILDER DECLARATION BUILDING PERMIT
o d'a MISC.- REFER TO ORD INFORMATION
w ; LL N I hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
.. O j Law for the following reason.(Sea 703 t.5,Business and Professions PERMIT ISSUANCE 10.00
� - Code:Any city orcounty which requires a permit m construct,alter,
a a¢2 improve,demolish,or repair any structure,Prior to its issuance,also ELEC.CONTR, LIC,NO.
ELEC.
La
-O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
K
$ he is licensed pursuant to the provisions of the Contractor's License ^
Fzi Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe L,B�
< Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
a r ca the basis for the alleged exemption.Any violation of Section 703 L5 STORIES TYPE CONSTR.
a ;m by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars 0500).p.
❑ 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 ARE. TOTAL ACREAGE
himselfor(hrough his own employees,provided that such improve- GAS-EA.SVSTEM-11NC.40UTLETS 6.00
mems are not intended or offered for sale.If,however,the budding
or .Prove is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 auaowc 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.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property.Pill exclusively contracting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC Y,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 thereon,and who LAWN SPRINKLERS-OV f5 A.) 1.00
contracts for such project's with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA. Oft/10:00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ lam exempt under Sea ,B.&P.C.for this WATER HEATERW/V NTr - 6.00
reason
Owner Date WATER SYSTEM s1 prCIS. ACC.-DATE ACC.FILE NO.
WORK ERS'COMPENSA'1'ION DECLARATION WATER TREATING EICLUM 5.00
I hereby affirm that I have a certificate ofeonsenl to self-insure, r 20NING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a cyrtified -
copy thereof(Sec.3800,Lab C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. n FIRE SPRINK ENERGY T 24
Z Z ❑ Cenif�,ssl cop is Filed with the city inspection division. I C REFER TO ORD. Y N Y E] N❑
APPlicanl� _ =�T -=-�
CERT IFICATF.OF EXFMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.O.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. �O oU v❑ N❑ v❑ NE]
O (This section need not be completed if the permit is for one TOTAL
0 Z hundred dollars IS 100)or less.)
U Q 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
UL I- mit is issued,I shall not employ any person in any manner so as to
Ow becomesubjecl to the Worker Compensation Laws of California. BUILDING
Date Applicant ALTER OR ADD TO MECH. 5.00
} rail NOTICE TO APPLICANT'. 11,after making this Certificate of Iix-
H ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN 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 ITO 10, 00C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 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(Sea HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.C.).
Lender's NameHEATING UNIT 10 VER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
. I certify that l have read this application and stab mthegmcv, VENTILATION FAN (SINGLE) 4.00 [90
information is correct I agree to comply with all ity a d county PLUMBING
ordinances and State laws relating to building nstru lion, and BOILEA-eOMPI3 H.P.or 100,000 B.T.U.) 6.00 ✓
hereby authorize representatives oI this city tt eatc upon the BOILER-COMPtOver100.000BTUISEEFEESCH. MECHANICAL
abovumentioned proper spection purpose.
(We) agree to sae indmnnif and keep h'e de the City of MISC.- REFER TO ORD.
o against liab s,judgfn nts, costs an xpenses i PERMIT ISSUANCE 10.00 CONST.TAX
ma, i any way accrue id City in c nen of[h
B,
ng Of this permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Si lure of Applicant/Contractor Date
OFFICE COPY