17836 APPLICANT TO FILL IN INFORMATIONAITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING �-r '3I �� APPLICATION & PERMIT - q
aAooREss
Z A S D BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OwNEP'3 ' A, 'D �� PLAN CHECK VALIDATION
NAME t"'�'YY XZ _^
TI ES �.r✓�IJ"f DTV. ELECTRIC PERMIT FEE
PRONE ✓'✓
CONTRAC OR
NAME , � UTLETS-SWITCHES-RECEP 10.00/1.00
uc No: LIGHTING FIXTURES 10.00/1.00
r-ONTRACTOR'y/4- PPLIANCES-RESIDENTIAL 4.00
A00 5
vHONE PANELS. 10.00 DATE OF APPLICATION
A.C. EC PLAN CHECK FEE P.C.NO.
on PANELS (OVER,200 AMP) 20.00
ENGINEER
uc.uo. - SIGNS TRANS. 3.00
ARCH ESS ENc. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS - SEE FEE SCH,
AOOR E65 I�/_ C
SERVICE CHANGE 20.00 "'!/
Ir o LICENSED CONTRACTORS UECLA RATION - _
Q U u 1 hereby affirm that I nm licensed under,,00isions of Chapter 9 �J • - ISSUANCE DATE
yaw (commencing with Section 7000)of Division 3 ofthe Business and (If_ -- - BOG. ELECT. 1 - PLG. - MECH.
F o z Prolessions Code,and my license is in full force and effect. -
z O w - License Class Lic.Number Jity
O F D Date Contractor
x s i BUILDING PERMIT
tZ w o OWNER-BUILDER DECLARATION INFORMATION
K
O a w I hereby u0irm that I am exempt from the Com mens.'.Licepse I - TO ORD
�+ I VALUATION 5/FT.
F LL o j Law for the following reason.(5<c.703 1,5,Business and Profesir p I 10.00
Code:Any city or county which requiresa permit to convmeL alter, n
a, ¢ a o improve,delnulish,or repair any structure,guru,to its issuance,also ELE . ON LI ELEC L
D ¢ requires the applicant for such pennit to file a signed statement that '/ TOT 5 PERMIT TO
w m w he is licensed pursuant to tins provisions of the Contractor's License ,
xi
Law(Chapter 9(commencing with Section 7000)of Division 3 of the '
a Business and Professions Cedc)or tlwl he is exempt therefrom and QTY. PLUMBING PERMIT FEE �r 1-/w
re F$ the basis for thcallegcd exemption.Any violation of$eetem 7031.5 ..- STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant ton civil penalty ALTER-DRAIN IEA.) 5.00
of not mob,than fico hundred doll...ISSOOM: V-I"I
❑ I,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. 7074, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Cale:The Contractor's License law docs not apply to an owner of
profrorty who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA OTALACREAGE
merits re through his own employers,provided that such imprma I�-7 (4.4
improvot e-
meritsintended oroemplo employee,,
ser e.provided
that suhcmprovg GAS-EA.SV STEM-11NC.40UTLETS 6.00
or improvement 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 of build or Im-
prove forpurloseofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PD -Omh•,
❑ I,as owner of the property,mn exclusively contracting with - 1.{f' ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL Na.
and Professions Cove; The Contractors License Lw does not apply
1..n Owner of progeny who builds cur improves Ihcrcon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contmctrono licensed puranno to
Orn Contractor's License Law, SEWER-SANITARY-STORM EA.20011/10.00 TRACTNO. PARCEL NO.
❑ lam exempt under Ser.-,BAP.C.for this WATER HEATER W/VENT 6.00
rea
on
Owner Date - WATER SYSTEM 5.00 ACC.DATE - ACC.FILE NO.
WORKERS'COM PE.NSA1'ION DO,CLARA'1'ION WATER TREATING EQUIP. 5.00
1 hereby album that I have a ernibcale of consent In self-insure. - ZONING ENG.SITE NO.
or a certificate of Workers'Comgemalion Insurance,or a certified
copy lhereci Sec.380 Lab.CJ.
Policy No. mpany '
O ❑ Ccrtibcd cu ,nc,cby furnished. FIRE SPRINK ENERGY T 24
z Z ❑ Cenibud pY + le w,ilh t dry inspection division.
O Ap ' and L �I MISC.- REFER TO ORD. - Y-❑ N❑ Y ❑ N❑
N ( 11'ICA'FF O k ISO, ION PROb WORKERS' PERMIT ISSUANCE 10.00 I2
FLOOD ZONE A.LU.C. '
LU > CONIPENSATION INSURANCE PLG.CONTR.' LIC.NO., PLG,� CI 1.4 v❑ NO[] v❑ NE]
CI section need not be emngletcd if tire permit rmit is for one TOTAL J
hundred dollar,IS 100)or lea.)
CJ O 1 certify that in the of the work for which this Icor- DTV MECHANICAL PERMIT FEE - FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner v+as to
O w become subject to the W'orkeri Compensalioo 1-.of California.
y Dam Applicant ALTER OR A
ICDD TO MECH:-. 5.00 BUILDING
} m NOTE 10 APPLICANT: If,atter making this Cenif<me of 17
� Z emption,you should become subject to the Workers'Conhpensmion APPLIANCE Y 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE '
U soon provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONS'1'RUCI'ION LENDINGAGENCY AIR HANDLING UNIT(OVER 10=11F.M.) 6.00 SEISMIC FEE g _
1 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 N. in - HEATING UNIT(OVER 100,000B.T.U,)9.50 51 '
Lenders Address ELECTRIC
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00 A_p
• information is conecl. 1 agree to comply with all city and county PLUMBING
o dinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.1 6.00 CJI
hcoven enthurd rep.senmtivrs of this city to enter upon the BOILER-COMP (Over 10Q000BTU)SEE FEE SCH. MECHANICAL 5I
shove-mentiuned pr perry fative g of
hi purposes.to.
(We) agree se, indemnify and keep harmless the City of MISC.- REFER TO ORD.
upertino a liabilities,judgments,costs and expenses which CONST.TAX !!v (�
say in ay accrue alai vid City in Co.. nee the PERMIT ISSUANCE _ 10.00 2 2 77/
win this Penni / MECH.CONT. LIC.N0. MECH.
.I , TOTAL I �= TOTAL /P_/ 0. /-
ature of App a ontractor Dat
OFFICE COPY