12855 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I ENTIFICATION I PERMIT NUMBER
BUILDING APPLICATION & PERMIT
X ADD ss
D I �. IL ING - ELECTRICAL-PLUMBING-MECHANICAL 12855
OWNERS PLAN CHECK VALIDATION
NAME r L 1 TY. ELECTRIC PERMIT FEE
1 ONE b
NOMERACTORs UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No, LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADDIN SS
PHONE PANELS 10.00XL7 DATE OF APPLICATION
ARCHITECTPLAN CHECK FEE .NO.
OR PANELS (OVER 200 AMP) 20.00 P
ENGINEER
LIC.NO ISIGNS TRANS. 3.00
ARC".OR ENG. SPECIAL CIRCUIT 5,00 TVALIDATON
ZIP TEMP.METER OR POLE INS. 20.00 ?3198
ADDRESS Ts MOTORS SEE FEE SCH. C%(jr ^.-
Of
SERVICE CHANGE 20.00
BE o LICENSED CONTRACTORS DECLARATION ,E
a o W I hereby affom that 1 am licensed under provisions of Chapter 9 ' ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
y BLDG. ELECT. PLG. MECH.
F z Professions Code,and my license Is in full force and effect. % 9 ❑ ❑ ❑
z o�, - License Class Lia Number
z r w Date Contractor
F x f W BUILDING PERMIT
Ic Q BE U OWNER-BUILDER DECLARATION I ORMATION
wN I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
.. wo j Law for the following reason.(Sec.7031.5,Businessand Profusions Code: ISSUANCE 10.00 VALUATION S/FT.
Code:Any city or county which mcHumsa permit to construct,alter,
SE
u,Q improve,demolish',or repair any structure,prior to its issuance,a)w ELEC.COKER. LIC.NO. ELEC.
DLL requires the applicant for such permit to file a signet statement that TOTA pE IT T
whe is licensed pursuant to the provisions of the Contractor's License
r z r Law(Chapter 9(commencing with Suction 7000)of Division 3 ofthc
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
BE r the basis for the alleged exemption.Any violation of Section 7031.5 STOMES TYPE CONSTR.
n ; by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER.IEA.15.00
of not mom 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 du 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 doe not apply to an owner of
^� property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SQ FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such aujim e-
menharenotintendedorofferedforsale.If.however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
bull r ill have the burden of proving that he did not build Or im-
prove purpose of.k.). INDUSTRIAL WASTE INTER. 30.00 REs IND coed PR Dena,
❑ as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
lice d contractors to construct the project(See 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
ea Profcssinns Codu:'fhe COnlraelm's License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a Contractors)liecusod pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200h/10.00 TRACT NO. PARCEL NO.
I em exempt under Sec. , C.'or this WATER HEATER W/VENT 6.00
reason
Owner' Uum WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKIiRs'COMPENSATION DECLARATIONB.&P. WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,lir a certified ZONING ENG.SITE NO.
ropy thereef(Sce.3800,Lab.C.L
Policy Nn. Company
0 ❑ Certified copy is hereby furnished.
FIRE SPRINK ENERGY T24
Z = .❑ Certified copy is filed with the City inspection division.
O Applicant MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
~ va
CER'TI FICATIi OF EXEMPTION PERMIT ISSUANCE 10.00 PTION FROM WORKERS' FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
a. Z( This section need not be completed it the permit is for one TOTAL Y❑ N❑ Y❑ N❑
hundred dollars IS 100)or IessJ
U O 1 certify that in the performance of the work for which this per. QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner so as to
become subject to the Workeri Compensation Laws of Califomia.
0 wa Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT. If,after HiAblg this Certificate of Ex
Z emption,you should berome subject to the Worker,'Compensation APPLIANCE _ 5.00 PLAN CHECK
provisions of the labor Code, you must forthwith comply with FEE
C7 such provisions or this permit shall be deemed revoked. - AIR HANDLING UNIT(TO 10=C F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.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 the permit is issued(Sec. MICROFILM.
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 Aluce to comply with all city and county PLUMBING
1 ordinances and slate laws relating to building ronstruction, and BOILER-ODMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purpose. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
r" (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupert p�ageinst liabilities,judgments,costs and expenses which PERMIT ISSUANCE ' 70,00 CONST.TAX
l may n any W per cru, st saW City U cunu9oence of he
¢fit n80f th4_P r,��rt.,.,.�1 MECH.CONT. Q N0. MECH.
x � tb524�\ TOTAL TOTAL
$�salu or,"reant/Contrxceor, L Date
OFFICE COPY