3508 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFI CATION APPLICATION & PERMIT ER BER
>( 801LOINGRESS 3508
ADD
lozoo
- BUILDING PLUMBING ELECTRICAL-PLUM
OWNER'S qqt,L O PLAN CHECK VALIDATION
WE '4573-,S9S8 QTY. ELECTRIC PERMIT FEE
PHONE
co TRACTORS �� OUTLETS-SWITCHES-RECEP- 5.00/1.00
E I
v/. l.A4VVV1. LiC.NO. - LIGHTING FIXTURES 5.00/1.00
CONT ESS TORS e'a//11 PPLIANCES-RESIDENTIAL 4.00
4311 ryG vHONE PANELS' S.00 DATE OF APPLICATION
ARCHITECT SIGNS 6,00 PLAN CHECK FEE P.C.N0.
OR
ENGINEER
LIC.NO, SIGNS TRANS. 3.00
ADDRESS cola SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APnucANr's .' MOTORS SEE FEE SCH.
ADDRESS � '
SERVICE CHANGE 10.00 /a f3
wo o LICENSED CONTRACTORS DECLARATION U
a v 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
yaw (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
Professions Co aT n license is in full lur�.'ya ❑e1. '
z o`8 Licenn Cl Lic.Numhcr;y" - I- - ❑. ❑ l�" ❑
o R Dale Contractor{
¢ x f BUILDING PERMIT
ar It w ¢ O NER-BUILDER DELLA RATIO\. INFORMATION
woaO MISC.- REFER TO ORD
; u_N 1 hereby affirm that 1 am exempt from the Contractor s License VALUATION $/FT.
,u u o ¢ Law for the following reason.(Sec.7031.5,Business and Professions ' PERMIT ISSUANCE 6.00
Code:Any city or county which requires o permit to construct,after,
¢ ta Q improve,demolish,or repair any structure,prior lO its issuance,also ELEC.CONTR. LIC.N0. ELEC.
E O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w m
rzi he is licensed pursuant to life provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe N�
¢ Business and Professions Code)or that he is exempt Therefrom and CITY, PLUMBING PERMIT FEE
¢ r O the basis for the alleged exemption.Any violation ofSection 70315 1 STORIES TYPE CONSTR.
n ; by any applicant for a permit subjects the applicant to civil penalty ALTER-DRAIN& VENT-WATER IEA.) 4.00
of not more than five hundred dollars(S500).):
- 0 1,as owner of life property.or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 : OCC.GROUP RES.UNITS
their sole nsa
competion,will do the work,and the structure n not
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does riot apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT FLOOR AREA TOTAL ACREAGE
himself or through his own cm ployee.......sided that such impravr
ments are not intended or offered for sale.Il',however,the budding GAS-EA.SYSTEM-I1NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 IEA) 100 9U a0fNG USE
builder will have the burden of proving that he did nm buil)ur inn- . . .
- RES IND CON PS Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 El ❑ El 1:1 1:1❑ 1.as owner of the property',am exclusively contracting with
licensed contractors to construct The police,(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V. 00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply .
to an owncrof property who builds Or improves thereon,and who LAWN SPRINKLERS-OV ER 5IE
contracts for such pmjeets with a co nraetons)licensed pursuant to
the Contractor's License Law. SEWER-SAN ITARY-STORMA 0 ft)8. TRACT NO. PARCEL NO.
0 I all exempt umder Sec .B.&P.C.t...[fits WATER HEATER W/VENT Z.
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSA'I'ION DEC[.ARArION WATER TREATING EQ 71P.-JILY 1.11 LOUP.W00 ,
I hereby affirm that I have a certificate of conscn Ll I sell'-insure. Iv �t t 0'0 ONING
or a Certificate of Workers Comp ation Insurance. a certified 1 z
ENG.SITE NO.
"x Copy thereof(See•3800,Lab.0 /A
Policy No. CmupanY s-a_OJ=-1t, S7 _
O U Cerlilied copy is hereby furnished. 5 .3 FIRESPRINK ENERGY T-24
Z Z 0 CertsVN copy is filed with th� c�ity'p/'/y"/�11�� T a ddi��visinn. MISC'- REFER TO ORD.
04 Applicarlt_4 c ""'�' `- v ❑ N Y ❑ N❑
CC y CERTIFICATE OF EXEMPTION FROM WORKER:' PERMIT ISSUANCE 6.00 FLOODZONE AL.U.c.
W > COAIPI NSATION INSURANCE PLG.CONTR. LIC.NO. v TOTAL !� ❑ N❑ ❑ ❑ .
CL 0 '('This section need not be completed if ,he permit is I'.r one v N
Z) Z hundred dollars(SI00)or Icss.)
U O 1 certify that in the performance of,he work for which this per- CITY MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any Intoner so as to
U hennne subject to the Workers'Compen,,mion Laws of Cahliunia.
d Dme ApplicantALTER OR ADD TO MECH. 4,00 BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
emption,you should become subject to the Workers'Compencitimi APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U 1.011 provisions or this pernit shall be deemed revoked. AIR HANDLING UNIT(TO JOXOC.F.M.) 3.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER IODWC.EM.) 5.00 SEISMIC FEE.
1 hereby afrrn'tha, 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 MICROFILM
3097,Cie.C.). HEATING UNIT 170 100,000 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 rad this application and statethat Th above VENTILATION FAN (SINGLE) 300
If. I Ref comply
sIlFit, I couny
PLUMBING
dtm c send rte f ws clot g to building construction. and BOILER-COMP 3 H.P-or 100,000 B.T.U.I 4.00
hereby authorize representatives s ntntives of this city 10 enter upon the
t jG
BOILER-COMP(Over 100,000 BTUI SEE FEE SCH. MECHANICAL
above mentioned property for inspection purposes
(We) agree tosave, indemnify and keep harmless life City of MISC.- REFER TO ORD.
Cupernno against liabilities,judgments, costs and expenses which CONST.TAX
ma In any,way accrue Against said City in consequence of the PERMIT ISSUANCE 3.00
gr ingottnPr it. q-W4"
�4MECH.CONT LIC.NT, MECH,
`� JTOTAL TOTAL
Signator CApplicant/Contractor Date
- OFFICE COPY