3181 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERr N
BUILDING APPLICATION & PERMIT 181
ADDRESS
BUILDING —ELECTRICAL—PLUMBING —MECHANICAL
OWNER' •- f"r'+"""': ,r-a- '"tG1�01 TL"°i"•f- e';;"�ti`!: PLAN CHECK VALIDATION
"AME OTV. •s !,r ELECTRIC PERMIT,. ��` r.:" �`� FEE,'
COACT 't 1
NAME °R5 LI
,3Q UTLETSWITCHES-RECEP 5.00/1.00 °'�
LIC.NO, GHTING F-SIXTURES 5.00/1.00
ADORE s r.Rs PPLIANCES-RESIDENTIAL 4.00
ADORE
PHONE PANELS 5-00 DATE OF APPLICATION
ARCHITECTSIGNS 6,00 PLAN CHEC77 P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCW OR ENG. SPECIALCIRCUIT 5,00 PE
RMIT
VALIDATION
ADDRSS
ZIP EMP.METER OR POLE INS. 15.00 ADDRESS MOTORS SEE FEE SCH.A.GREssSERVICE CHANGE 10.00DWoo LICENSED CONTRACTORS DECLARATION _O 9
a u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
zw. (commencing with Section 7000)of Division 3 of the Business and
vt 6 c BLDG. ELECT. PLG. IT.
r 0 i Professions Code,and my license is in full force and effect ❑ ❑B License Class Lin.Numbero m Date Contranor '.:BUILDING PER¢ ¢¢ a OWNER-BUILDER DECLARATION <o a u J',.41NFORMXTIONw ; N I hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD0Law forthe followin mason.ISec.7031.5.Business and Professions VALUATION
r — ,A a PERMIT ISSUANCE 6.00
F ,A0F Code:Any city or county which requires a permit to construct.alter,
is a ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. aM
wO LL requires the applicant for such permit to dile a signed statement that TOTAL pERMIT TO
$ he is licensed pursuant to the provisions of the Contractor's License
r Law(Chapter 9(commencing with Section 7000)of Division 3 of the ' ,f'?Y'"I.
fi o Business and Professions Code)or that he is exempt therefrom and OTV. •1�,^,jY�••"PLUMBING.PERMIT •a. ,.'r, - FEE j
at the basis for the alleged exemption.Any violation.(Section 7031.5 -F' p•�Y;- ,3•,, ,^riC,:rTa h :.: •'.^3 <, STORIES TYPE CONSTR.
by any applicant for permit subjects the 0).):ant last Civil penalty ALTER-DRAIN -WATER (EA.) 4.00 _
of not mote Than five hundred dollars(5500).1:
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sale 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 Contractors License Law does not apply to an owner of
property who builds or improves thereon.and who does such work FIXTURES-PER TRAP 4.00 SM FT.FLOOR AREA TOTAL ACREAGE
himself..flamoillnot
ownemployees,for Sale.
if.ed however.
the
improve- GAS-EA.SYSTEM-I INC.4 OUTLETS 4,00
meats are not intended or offered for sale.If,however,the building
or improvement is wld within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1,00 BUILDING USE
builder will have the burden of proving that he did not build or im-
prove for purpose of sale.). RES IND CON Pe O,ne,
❑ 1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ 13 ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPR IN KLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Cade: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 contmctons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec.—,B.&P.C.for this WATER HEATER W/VENT 4.00
ea
Dat owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate ofconsem to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy N.. Company ,
C) ❑ Certified copy is hereby furnished.
FIRE SPRINK ENERGY T24
Z Z ❑ Certified Copy is OIeJ with the city inspection division. MISC,- REFER TO ORD. 0 ❑
O Applicant Y N Y N
= N CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.,.
LU COMPENSATION INSURANCE PLG.CONTE. LIC.NO. 710M
tl O (This section need not be completed if the permit is for one TOTAL Y C] NE] Y NE]
U O hundred dollars IS 100)or less.) • t,MI d
I certify that in the performance of the work for whish this per S - - . ��+" " Y sY t_,35PEE SUMMARVp ''t F•'
I ALJ4RFEE;( w
LL )- mit is issued,1 shall not employ any person in any manner w as m CITY.
MECHANI
__ , -t ._ti ar„• t+
0 W becomesubject to the Workers'Compensation Laws of California.
Date Applicant ALTER OR ADD TO MECH. 4.00
} sail NOTICE TO APPLICANT: If,after making this Certificate of EC. BUILDING
F 2 emotion,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit Shull be deemed revoked. AIR HANDLING UNIT(TO lOF)00 C.F.M.) 3,00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10p00C.F.M.) 5.00 SEISMIC FEE
I hereby affirm (hat there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued ISec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)7.50 be
Lenders Address ELECTRIC
I certify that I have read thisapplication and slain Ihm the above VENTILATION FAN (SINGLE) 3.00
. information is correct. I agree to comply with all city and countyBOILER-COMPI3 H.P.or 100,000 B.LU.) 4.00 PLUMBING
ordinances and state laws relating to building constrr C.60n, and
hereby authorize representatives of this city to enter upon the Oe
above-mentioned property for inspection purposes. BOILER-COMP lova.t00,0008TU15EE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
C rtmo against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
Y
m any ay ace a against said City in Consequence of the
nhn fth prmil MECH.CONT. LIC.NO. MECH. ` .5?t-py!(x;:y.�!,k4 r•§
TOTAL
ra �23 �� " rT}O' TAT. S
Signature o7A tic t/Contractor Uwe �I% " 'LI �^
v /J/,(/-,�— 9__- n 9,,f"'='OFFICE COPY