11329 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS 11329
EZ kJBUILDING-ELECTRICAL-PLUMBING-MECHANICAL
NEIL'S PLAN CHECK VALIDATION
.� NAME DTV. ELECTRIC PERMIT FEE .
� ,v 'L,J D,V PHONE L177 _
CONTRACTOR p / UTLETS-SWITCHES-RECEP 10.00/1.00
�I *L_ A-r?O LIC ND <{u7 LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
qaCNE //y PHONE y yep PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIc.No. SIGNS TRANS. 3.00
ARCH,OR ENG. SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00 �r
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 & -k/,f{-�/z
w 0 O LICENSED CONTRACTORS DECLARATION �J[ " '
is
is u I hereby of on that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w¢H (commencing with Section 7000)of Division 3 of the Business and BLDG. I ELECT. PLG. MECH.
F y z Professions Cod on license is in full fur I f c. h ❑ ❑
Z,O a- License lass q. Lic.Nwnber ta4-
4 L r w Date `I t Contractor
a Y s BUILDING PERMIT
Ic IS u OWNER-BUILDER DECLARATION INFORMATION
Woe I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
uO Law for the following reason.(Sec.703 L5,Business and Professions VALUATION S/FT.
Code:Any city or county which requires a permit to construct,alter,is PERMIT ISSUANCE 10.00
rt Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO, ELEC.
-CLL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n w.9 m m
hes licensed pursuant to the provisions of the Contractor's License
r Law(Chapter 9(comencing with Section 7000)ofDivision 3 ofthe -
f 4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
IS I-$ the basis for the alleged exemption.Any violation of Section 703 L5 STORIES TYPE CONSTR.
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($500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
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,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
I � property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 $0.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00 t{
orimprovement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im" RES IND CON PB Omer
prove for purpose of sale.). IN D LIST RIAL 7VASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ El
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 Low does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.1 1.00
contracts for such projects with a contractor(a)licensed pursuant to'
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ALC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
ar a certificate of Workers'Compensation Insurance,or a certified
copy titer S c B 0 Lab,G.). ,SS RM
policy NoJ pany.�) �•
O ❑ Cerlified copy is hereby furnished. I FIRE SPRINK ENERGY T24
Z Z X Certifie c pyyis II lh the city inspection division. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
O Applicant L- V N V N
F_ mPERMIT ISSUANCE 10.00 FLOODZONE A.t.O.C.
LU j CIiRTIPICATE E 1; TIO TINS FROM WORKERS'
11J _ COMPENSATION INSURANCE. - PLG.CONTR. LIC.NO. PLG-.-: V❑ N❑ Y❑ NE]
Z)
(This section need not be completed if the permit is for one TOTAL
Z) Z hundred dollars($100)or less.) Q
U O 1 certify that in the performance of the work for which this per. OTV. MECHANICAL PERMFf FEE FEE SUMMARY
LL F mit is issued,1 shall not employ any person in any manner so as to -
U become subject to the Workers'CompenmtmG Laws of California. BUILDING
O y Date Applicant ALTER OR ADD TO MECH. ( $.00
m NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.0 PLAN CHECK
pro /100
visions of the Labor Code, you must forthwith comply with a FEE
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10 .M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance 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
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 OTL PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100.00OBTUI SEE FEE SCH. MECHANICAL /
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REF TO D- CONST.TAX
Cuperli against liabilities,judgments, costs and Expenses which PERM SUANCE .00 /Q
ma in any way accrue against i City inconsequence of the
gr' tin of this peranit ag
MECH.CONT. LIC.NO, MECH.
y��� T°T'e/102/L O- TOTAL
Signature of pplicanl/ ontractor Dale {Y
OFFICE COPY -