8756 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ON1?Y
9UILr,NG
BUILDING PROJECT IDENTIFICATION at PERMIT NUMBER
APPLICATION & PERMIT
aooREss 8756
BUILDING- ELECTRICAL-PLUMBING-MECHANICAL
OwNER'S ��rrvv PLAN CHECK VALIDATION
NAME C b i G2 i OTY. ELECTRIC PERMIT FEE
i
NAMERAcraRs UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO. LIGHTING FIXTURES 10.00/1.00
CONTRADRRAcrDRs
ADPPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
OR
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
eooa'ESS END' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20,00
ADDRESS s MOTORS SEE FEE SCH.
AD
SERVICE CHANGE 20.00
w 0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE 3400 '
a i c I InEmby affirm that I can licensed under pmvimax.1-Chapter 9 ISSUANCE DATE
y¢ m (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. P MECH.
r N z Professions Code,and my license is in full force and effect. ❑ ❑ ❑
o 0 m- License Class Lic.Number
Date Contractor
F yr F J
¢ se s J !BUILDING-PERMIT P
a O n OWNER-BUILDER DECLARATION ; - INFORMATION
X ; v I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
u 0 ¢ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION /FT.
� - at -' Code:Any city orcounly which requires a permit to construct,alter,
E I
In 2 ¢ O improve,demolish,or repair any structure,prior to its atem ent also ELEC.CONTR.- LIC.N0. ELEC.
In DLL requires fI1C applicant for such permit 4s file a signed stale-Ilteal that TOTAL PERMIT TO
Er
he is licensed pursuant to the provisions of the Contractor's License rI//✓_)
r z i La.(Chapter 9(commencing with Section 7000)of Division 3 ofthe
¢ Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
ii o
n. I- $ by basis for the alleged exemption.Any violation otoaction malty 5 RIES TYPE CONSTR.
i ; � by anyapplicantfive permit subjects the O).): an[toacivilpenalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(my employees
❑ Las owner of the property,or my,and t e s with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and 05e structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractors License Law does not apply to an owner of
property who builds ar improves thereon,and who does such work FIXTURES,PER TRAP 5.00 SO,IT,FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided that such improve.
hieats mself a not through
oroemped for loyeesale,Ii,however,ded that suhebwlding GAS-EA.SYSTEM-1INC.4OUTLETS 8.00
ar improvement is sold within one year of completion,the owner. GAS.EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or an- BUILOING USE
RES IND CON PS Other
prQvp for purpose of theJ. IND TRIAL WASTE IN TER. 30.00
en 1.d as owner of the property,he exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed colons od to construct the project(Sec. 7044,Business LAWN SPR W KLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to anowner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such orojems with a cont etor(s l licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
laicense Law. TRACT NO. PARCEL NO.
the
❑Colnarm cto�mot under Sec. .&P.C.for if WATER HEATER W/VENT 6.00
n - WATER SYSTEM 5,00 ACC.GATE ACC.FILE NO.
C MPE ATION I ECLAR I WATER TREATING EQUIP, 5.00
I hereby affirm that I have a certificate ol'co enl to self-insure,
or a certificate of Workers'Compensation Insurance,or a"Rified ZONING ENG,SITE NO.
copy thercoflSer.3800,1-ab.C.).
Policy No. Company _
O ❑ Cenifmd copy is hereby furnished. - - FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.O Applicant Y ❑ N[] Y [:] NE]
CC00
LU LOCIiItTI PIC ' P EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10. FLOOD ZONE_ A.L.u.C.
W >_ CCIOMPIiNSAT'ION INSURANCE PLG.CONTR, LIC.N0. PLG. '
CL 0 (This section need not be completed if the permit is for one TOTAL 40C Y❑ N❑ Y ❑ N❑
Z hundred dollars IS 100)or less I
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL f mit is issued,1 shall not employ any person in any manner so as to
Q L) become subject to the Workers'Compensulion Laws of California.
Date - Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} 0 NOTICE '1'0 APPLICANT: 11,after making this Certificate of Ex
F Z emotion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must lorlhwilh comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10000C.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 this permit is Issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name H EATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have nod this aPmlyn and state that the above VENTILATION FAN (SINGLE) 4.00
information to comply correct I agree y with all city and County PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP I3 H.P.Or 100,000 B.T.UI 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Oven-100,000 BTU) FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemni and keep harmless the City of MISC.- REFER TO ORD.
Cuperl' most liabilities,TO g ents costs and expenses which PERMIT ISSUANCE 10.001 CONST.TAX
ma any way accrue aga' .i onsequence of the
gofl perfhi4 MECH.CONT. LIC.NO. MECH.
. ��
TOTAL TOTAL
Signal r o pplicant/Co tractor D e
OFFICE COPY
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