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. BUILDING PROJECT IDENTIFIrATIAL I
APPLICATION & PER
BUILDING -ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
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aDILpnV
A.NIE
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rvAmE
C✓ if /y0 /rJ PHON
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
CON RACTOR'S
rvamEOUTLETS
_IC.NO.J;r'?e9,ff
- SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
PE OX S324!>PHONE] p0
DATE OF APPLICATION
ARCHITECT
OR
ENGINEER
uc. NO
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
ISIGNS TRANS. 3.00
AARCH, OR DDRESS ENG.
SPECIALCIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
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ADDRESS
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code and m license is in full force a W eft--ecyy --''
License Class �7.._Lic.lgarr J_sL
Date/ 41)�'_?!-ConsractorStr�
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason.(Sec. 7031.5, Businessend Professions
Code: Any city or county which requires a permit to construct, alter,
DATE
VLD ELECT. PLG. MECH.
❑ ❑ ❑
BUILDING PERMIT
INFORMATION
MISC.- REFER TO ORD
pERMIT ISSUANCE 10.00
VALUATION
S/FT.
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
PERMIT TO
QTY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencingwith Section 7000)of Division 3 of the
Business and Professions Code) or (hal he is exempt therefrom and
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant On civil penalty
of not more than five hundred dollars (8500).):
ALTER -DRAIN -WATER IEA.) 5.00
❑ 1, as owner of the property, Or my employees with wages as
their Sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
ments are not intended or offered for sale. If, however, the building
or improvement is Sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im-
prove for purpose of sale.).
I, as owner of the property, am exclusively contracting with
F IXTUR ES - PER TRAP 5.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
GAS-EA.SYSTEM-11NC.40UTLETS 6.00
- . -..
GAS EASYSTEM OVER 4 IEA) 200
BUILDING USE
RE IND CON PB Other
❑ 11❑
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 IEA.) 1.00
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: 'I'lie Contractor's License Law does not apply
to an owner of property who builds or improves thereon, and who
ASSESSORS PARCEL NO.
contracts for such projects with a contractoAs) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ 1 am exempt under Sea ,B.&P.C. for this
reason
WATER HEATER W/VENT 6.00
Owner Dale
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO,
WATER TREATING EQUIP. 5.00
WORK ERS'COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent to self -insure,
or a certificate of Workcrs' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof (Sec. 3800, Lab.CJ.
Policy No. Company-
FIRE SPRINK
Y [] No
ENERGY T-24
Y E) N[]
❑ Ce 'tied cop is hereby turn' ed.
i'e is f d II ty Ins ec(yon sion.
Applicant ` �+n' /�
MISC. - REFER TO ORD. '
.RTIPICA'I'E OF EXEM ION PROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U.C.
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
PLG.CONTH. ❑C. NO.
PLG.
TOTAL
Y 0 N�
Y ❑ NC3
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars 1$100) or Iess.)
I certify that in the performance of the work for which this per.
mit is issued, I shall not employ any person in any manner so as to
BUILDING
become subject to the Workers'Compensation Laws of California.
Date Applicant
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption, you Should become subject to the Workers' Compensation
APPLIANCE 5.00
PLAN CHECK
provisions of the Labor Code, you most forthwith comply with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10000CF.M.) 4.00
AIR HANDLING UNIT (OVER 10=C.F.M.) 600
SEISMIC FEE
R` --AI
CONSTRUCTION LENDING AGENCY
hereby Orion that there is a constmctinn lending agency bar
EXHAUST HOOD (WITH DUCT) 5.00
.the performance of the work for which this permit is issued (Sec.
3097, Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
Lender's Name
Lender's Address
I certify that I have read this application and state that the above
VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
BOILER-COMP(3 H. P.orlOO,000B.T.U.) 6.00
BOILER -COMP (Over 100,000BTUISEE FEESCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
CONST. TAX
(We) agree to save, indemnify and keep harmless the City of
hmuapy eLino ,gainst liabilities, jud ats, ousts and expenses whichpERMIT
y way accrue ai id City in consequence of thetin o his permit 1
-3'
ISSUANCE1000
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
alone oyApptrearfl/Conlractor Uam
OFFICE COPY