17830 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LD1 NG PROJECT 1 DENTI FICATION .PERMIT NUMBER
BD"°'"GT 25A APPLICATION & PERMIT 17SOO
ADDRE S
[� A Ica Civ BUILDING - ELECTRICAL-PLUMBING-MECHANICAL _
OWNER'S 1 w, `O�n rp 1� PLAN CHECK VALIDATION
NAME lJ-1 M11 1 Y'�r-"'r_
=YLTI�S4- DTV. ELECTRIC PERMIT FEE
PRONEfT 3 %
CONTRACTOR j��fp♦y/J,n .LiUTLETS-SWITCHES-RECEP 10.00/1.00
NAME �!�/,lA�/�I�
LIC.NO. LIGHTING FIXTURES 10.00/1.00
r-ONTRACTOR / D PPLIANCES-RESIDENTIAL 4.00
Ao Ess
PRONE PANELS 10.00 DATE OF APPLICATION
C ECT PLAN CHECK FEE D.NO.
OR - PANELS (OVER 200 AMP) 2(1.00 .
ENGINEER - '
uc.No. SIGNS TRANS. 3.00 '
ADDRESS ENG
3PECIALCIRCUIT 6.00 PERMIT VALIDATION
°"PLICANTS
ZIP EMP.METER OR POLE INS. 20.00 �-.(
MOTORS SEE FEE SCH.
AOORE55
SERVICE CHANGE PAP, 20.00
0 ce 0 LICENSED CONTRACTORS PLL'L RAA//j���'IO 3'� - I!U
Qu v hereby uflirm Ilial I am licen> nfll iAlOL E' tAAY y IJ Lf ISSUANCE DATE
z w (commencing with Section 7000)dddd Uiv ddd��d11111111177777T''"'rf(in B c u
res ¢ vAi BLDG. ELECT. PLG. MECH.
H m z Professions Code,and my license is II a 1 c - I[71 -
z o u, - License ClassLie. u X 1L a
4 z H 0 Dam Cont r CI" of Cnnartinn
a r E Z
OWNUILDING PERMIT
¢ ¢
OWNER-BUILDER DECUGC ON
b� MISC-- REFER TO ORD INFORMATION
w ; N I hereby affirm that I am exempt from On,Contractor's Liceme ' VALUATION S/FT.
aa LL O v, Law for the following reason,(Sea 7031.5,Businessand Professions
us Code:An 't or count which requires t to construct,alter, PERMIT ISSUANCE 10.00 IZG
city n w r mi 119 CCO -
ar w ¢ improve,demolish,or repair Any structure.Prior lO its icsuanw,also ELEC.CONTR. LIC.NO, 'ELEC.
w ¢ O ¢ requires the applicant for such permit to flc a sincd statement that TOTAL 4q05
A w w he is licensed pursur it to the provisions of the Contmetoi s License PER MIT TO
Hz ¢ Law(Chapter 9(cmudnencingwith Section 7000)of Division 3 ofthe
Business and ProfLvions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE �--I ✓1�-ff�
IS =0 the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d � by any applicant for a permit subjects the a,plieant to a civil penalty ALTER-DRAIN 5.00 1I
of not more than five hundred dollars(55001.): V-14
❑ h es owner of the properly,or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compuns flon,will do the work,and the structure is not
intended or offered fur sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00e
CodThe Contractor's License Uw does not apply to an owner of
property who builds or improves thereon,unit who docs such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve- ` GA,)Q
ments are not intended oroffend for sale.It,however,m14e building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00 VV,
improvement provement 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-
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
RES IND CON PB Omer
❑ I,as..net of the property',am exclusively contracting with L ❑ ❑ ❑ ❑
licensed contractors to construct the project(See 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 an owner of property who builds or improves mer ,er,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts forsueh projects with u conlruutorls)licensed pursuant In
the Contractor's Llccnse Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I em exempt under Sea ,B.&P.C.for this WATER HEATER W/VENT 6.00 .
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure. TONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certil ted
copy thereof(See 3X00,Ub.C.).
Policy co. m-aany ♦ '
O Cl Crlifcdc6reby furnished. FIRESPRINK ENERGY--24
cry/
Z 2 ❑ Cerrifi�d is filed wit ,11e yny innpecliun division.
Apple" ///// / n MISC.- REFER TO ORD. : r ❑ N❑ r ❑ N❑
Mtn HC.TIi I°EX oS I N" MM RKGRS' PERMIT ISSUANCE 10.00
FLOOD ZONE A.LLLC.
W > COMPENSATION INSURANCE PLG.CONTE. LIC.No. PLG. �j 0Cj r❑ N❑ Y❑ N El Z (Thu section need not be, completed if(lie permit is for one TOTAL _I
Hundred dollars IS I W)or less)
U O 1 cenify that in the performance of the work For which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mil is issued,I shall nor employ any Poem in any manner so as to
U become subject to thin Workers'Compensation Laws of California. �[J
Un, Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE 'ID APPLICANT: it,after making this Ccrtilicate of Gx-
2 emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must furthwifh comply witII - FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MOC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 6.00 SEISMIC FEE a
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the perfurman¢ of the work for which Ibis Permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(To 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 �CjO5
Lender's Address ELECTRIC
Icertlty feat l havoread this application and slate that the above VENTILATION FAN (SINGLE) 4.00 ���
^ inr
fomation is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction. and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
Hereby enthori4c representatives for ins of this city to enter upon 0m BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL �05
above-mentioned property for inspection puity to
(We) rupee to save, indemnify and keep harmless the City of MISC.- - REFER TO ORD. ?3�
upertmo a t liabilities,judgments, costs and cxpensos which PERMIT ISSUANCE 10,00 CONST.TAX �a.'7
1
tan in uY eine agai t sail City in co encC f the )7r1
rantin his pU IL MECH.CONT. LIC.NO. MECH. - -
TOTAL
a re o(A phcunt Contractor ♦ D5 TOTAL ] r
2D to �
OFFICE COPY