6933 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
1 BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
amLOING APPLICATION & PERMIT 6933
ADORES
n. D 7 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
NE
NH'SS / G PLAN CHECK VALIDATION
E / / QTY. ELECTRIC PERMIT FEE
ONE
�� - c AT s UTLETS-SWITCHES-RECEP 5.00/1.00
uc.No. / LIGHTING FIXTURES 5.00/1.00
NTRAOTO 's ^ RESIDENTIAL 4.00
A nORE55 j//
k` PHONE PANELS - 5.00 GATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.N0,
OR
ENG W EER
uc.No. SIGNS TRANS. 3.00
ARCRE55 E �7 - SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
Za ZIP EMP.METER OR POLE INS. 75.00 ^ 1 ('
ADDRESST MOTORS SEE FEE SCH. (_/, J
ADDRESS
SERVICE CHANGE 10.00
0 0 o LICENSED CONTRACTORS DECLARATION /
G U v I hereby affirm that I am licensed under provisions of Chapler 9 ISSUANCE DATE
( omm acing with Section 7000)of Division 3 of the Businessand BLDG. ELECT. PLG. ` MECH
r '6" Professions Code nd my license is In full fon,q /;fife A
z o m I L' ase Class_ha Number l 'T ❑ ❑ ❑
O z r o Date Cont Factor t
a x s 'S '✓ BUILDING PERMIT
IF OWNER-BUILDER DECLARATION INFORMATION'-
I
o a REFER TO ORD
w3 LL N I hereby al7inn that I nm exempt from the Contractor's License MISC.-
i. Oj Law for lire following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE VALUATION 8/FT.
r - Code:Any city or county which requires a permit to constmcLalteq 6.00
E m > f p pair any slmcturc,prior ELEC.CONTR. LIC.NO. //0 00 OL T
¢ a O improve,demolish,or re or[o its issuance,also ELEC. /
in
- o ¢ requires the applicant for such permit to file a signed statement that . TOTAL PERMIT TO '
a w m a he is licensed pursuant to the provisions Of the Contractor's License ��]]
EZQthT
Law /4/ Yz/UK �CC/f'/o4
i O Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT st FEE
a i- is the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
ate _ by any applicant fora permit subjects the applicant ton civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more titan five hundred dollars(5500),):
❑ .L as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 occ.GROUP REB,overs
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,CON D. 4.00 -.
Code The Contractors License Law does not apply to as owner of _
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 s0_FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments
mprovements are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
or improvement is sold 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 Ile did not build Or am-
p
coca for purpose cf,dr.). INDUSTRIALWASTE INTER. 20.00 RES IND CON PB Omer
O 1,as owner of the properly,am exclusively contracting with '❑ E] ❑ ❑ ❑
licensed contractors to construct the project(Sec 7144,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs not apply
to u I Owner of property who builds of improves thereon,and who LAWN SPRINKLERS-OVER 5(EA'.) 1.00
1 - contracts for such projects with a conlraaons)licensed pursuant to
the Contractor's License Law. - SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec ,R.&1'.C.for this WATER HEATER W/VENT 4.00
reason
Owner Dale WATER SYSTEM 4.00 ACC.OATE ACC.FILE NO,
WORK r RS'COMPENSATION DlicLnllnTlDN WATER TREATING EQUIP. 4.00 -.
I hereby affirm that I have a certificate of consent sell=ins re ZONING
ur a ceriifmate of Workers'Comoro t In' 'nee, a cert' ia1 ENG.SITE NO_
copy thereof(Sec,3800,Lab.C.). <
Policy No. Canpany YYY C
Q ❑ Ccrtifi'd opsIIyd
l'pmishe1 FIRE SPRINK ENERGY T24
❑ Certifie o with the city inspection diviion.P2� ApVhcanl yy MISC.- REFER TOORD. Y ❑ N❑ Y ❑ N❑CEAll I•ATI? :MPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOOZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC,NO, PLG.
0- O ('This section need not be completed if the "emit is for one TOTAL Y❑ N❑ Y❑ N❑
::) Z hundrtd dollars IS 100)Or less)
U O 1 certify that in the performance of lire 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 hccome subject m lire Worker,'Compensation Laws of California ��-�pp
ED Dam Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} w NOTICE '10 APPLICANT: If,after making this Certificate of Ex-
1..- Z ennplion,you should becOmC subject to the Workers*Compensation APPLIANCE 4.00 PLAN CHECK
"'.visions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000GF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER 10MC.F.M.) 5.00 SEISMIC FEE• F 70
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the perfornance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name - HEATI NG UN IT(OVER 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 t0 comply with all city and county PLUMBING
ordinances and slate laws relating to building construction, and BOILER-COMPI3 H.P.or 100,0006.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-menti.ned property for inspection purposes.
(We 1pa KHiZ,
, ndemnify and keep harmless the City of MISC.- REFER TO ORD.
CuVer R agi les,judgments, vests and expenses which CONST.TAX
may iinyaanst said City l cense uence of the PERMIT ISSUANCE3.00granum of tMECH.CONT. LIC.NO. MECH.a // TOTAL TOTALtocI /Contractor /Date
INSPECTOR COPY