8196 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATIO PERMIT NUMBER
BUILDING APPLICATION & PERMIT g199
ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
O R _PLAN CHECK VALIDATION
ME OTV. ELECTRIC PERMIT FEE
HONE
NA " ° UTLETS-SWITCHES-RECEP 10.00/1.00 .1(s G o /]•/��
W. LIC.NO, LIGHTING FIXTURES 10.00/1.00
AONil"FEss dfohl'slvgAPPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ECT PLAN CHECK FEE P.C.NO.
on E�(�V�,! 0���/�/ PANELS (OVER 200 AMP) 20.00
ENGINEER '-/f-
LIC.No. SIGNS TRANS. 3.00
ARCH.ORENG. / /�O PERMIT VALIDATION'
AGOREss SPECIAL CIRCUIT 5.00
ZIP EMP.METER OR POLE INS. 20.00 r
APPLICANTS / MOTORS SEE FEE SCH. J
ADDRESS
SERVICE CHANGE 20.00 3 y
o o LIC1.NSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a v u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
m G w (conn..engin,with Section 7000)of Division 3 0l the Business and BLDG. ELECT. PLG. MECH.
r y z Professions Code un my 'cense is in full for • h l ff El 101
1:1 LEI hicenu Class oNunilrc
Z,mO m -H � Date 4 Contractor- '
¢ m s LI •.:/ BUILDING PERMIT c
ceao e u OWNER-BUILDERUECLARA'rboN INFORMATION
w I- I herebyffrm that I am exempt from the Contractor's License MISC.- REFER TO ORD
a P VALUATION $/FT.
FuoJ Law for the follia.mgreason.(Sec.7031.5.Busincssand Professions PERMIT ISSUANCE 10.00
Code:Any city or coumy which reyuiresapermit mconshuct.a0eq
i //1Mo �'`ll
¢ ¢ o
improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. UCNO
. . ELEC. /V /
O LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
A ce re he is licensed pursuant to the provisions of the Contractor's License
F i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
¢ Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE �N%• C N/OCG G
re I oo the basis for the alleged exemption Any violation of Section 7031.5 STORIES TYPE CONSTR.
u ;m by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(5500).1:
❑ I, er owner of the property,or my employees with wagesas BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their Sole con'pensation,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:T'he 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 SQ IT.FLOOR AREA TOTALACREAGE
• - himself or through his own employers,provided that such improve-
mems are not intended or offered for sale.11,however,the building GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE I NTE R. 30.00
❑ .1,as owner of the property,am exclusively contracting with ❑ El El ,❑ Cl
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to as owner of property who builds or improves thereon.anA who LAWN SPRINKLERS:OVER 5(EA.) 1.00
contrucis for such projects with a contractimsl licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
scorn))
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to self-insure, ZONING
or a curtificutc of Work c is'Coupe nation Insmunea,nr a certified ENG.SITE NO.
copy fl cool'I Sec.3800,Lab.CJ
Policy No. Company VAIA
O ? CeRH-I 1 0'op is ltereby( r c .n ff� y�Iyy� FIRE SPRINK ENERGY T24
Z ZO \ CeNIri d o lh th r h t -0h MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
Applicant hs V N V N
CC CERT'I \ HOT ESE. T N pR /WORKF-RS' PERMIT ISSUANCE 10.00 FL000 zoNE A.LU.L.
LU OAIPEISATIONINSURA, CE PLG.CONTR. LIC.NO. PLG. y❑ N❑ V ❑ N❑
CL Z T
( his section need not be completed if the permit is for one TOTAL
hundred dollars(S 1001 or less.)
U O 1 certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any manner so as to
O become subject to the\Yorkers'Compensation Laws of California.
UJ
DateApplicant BUILDING /QN,7
cj
} so NONCE 'FIT APPLICANT: R,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00 G
2 enhptim,you should become subject to the Workers"Cmnpenmtion APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be dcumed revoked. AIR HANDLING UNIT(TO 10,000OF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE 7 U PG
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the perfnrmmoce of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
nlormation is correct, I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-CDMP(3 H.P.Or 100,000 B.T.U.) 6.00
hereby authorise representatives of this city to enter upon the BOILER-COMP (Over 10Q000BTU15EE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Misc.- REFER TO ORD.
C ¢tlino against liabilities,judgments, costs and expenses which pERMIT ISSUANCE 10.00 CONST
.TAX
m in an way accrue against said City in amseyu,P,c of the
g n hgo is permit MECH.CONT. LIC.NO. MECH.
TOTAL
TOTAL ) 7•S-3 Uv
Sig tj,,,of Apfrican?gN, tff Date
INSPECTOR COPY