18033 L APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALt POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
pLBUILDING �e APPLICATION & PERMIT 18033
2( , (,LyVL•�I�(,,� �Jf. BUILDING - ELECTRICAL-PLUMBING -MECHANICAL Y!d.
NwMERSPLAN CHECK VALIOATION-
ctial�-ok�yha►r 144' -2-]lip O V. ELECTRIC PERMIT FEE
ONE
CONTRACTORS
NArr,,�' '' .y� ^�I UTLETS-SWITCHES-BEGET 10.00/1.00
. fI1 las t�`.""-^-n LC.NG4�!- � to LI TING FIXTURES 10.00/1.00
CONTRACTOR'S '
AD R�Es'/s�, MS{- �3q_C)s-(b PPL NCES-RESIDENTIAL 4.00
0bMO/ PHONE PANELS 10.00
ARCHITECT DATE OF APPLICATION
PLAN CHECK FEE P.C.NO.
I
on PANELS (O R 200 AMP) 20.00
ENGINEER
C.No. SIGNS TRANS, 3.00
ARCH 08 ADDRESS ENG. SPECIAL CIRCUI 5.00 PERMIT VALIDATION
1 ZIP TEMP.METER ORP E INS. 20.00
y aooliiATS MOTORS SEE FEE SCH. �•/-1������1
15;5 '�"`" `�1 SERVICE CHANGE 20.00 ��� (�,�,�+jq
o o LICENSED CONTRACTORS DECLARATION M ,
a u 1 hereby affirm that I am licensed under provisions of Chapter 9
,HA a w (commencing with Section 7000)of Division 3 of the Business and ISSUANCE DATE
H H i Professions Code, ul iceri is in full lout, f. /.. - !T11
ELECT. PL❑G. ME
o z m o License Clan{{{{ Lie.Number b
Ua[e Contractor_
Q Y J
¢ ¢¢ a OW ER-BUILDER DECLARATION BUILDING PERMIT
s0 su MISC. REFER TO ORD INFORMATION
w g LL I hereby alfrm that I am exempt from the Contractor,License _
u O a Law for the following reason.(Sue.70J 1.5,Business and I'ro fession, VALUATION $/FT:
PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to conslrucL alts,,
a ¢ ¢p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O¢ requires the applicant for Such permit to file a signed statement That TOTAL
A w m m Ile is licensed pursuant to the provisions of the Contmetois License PERMIT TO
rz >
Law(Chapter 9(commencing with Section 70001off)msion 3 eftlle
f 4 o Business and Professions Code)nr that he is exempt therefrom and G V. PLUMBING PERMIT FEE 1 1g-L-CP VVI�/i L�
¢ H$ the basis for the alleged exemption.Any violation of Section 7031.$ STORIES TYPE CONSTR.
a3 � by any applicant for a permit subjects the applicant to a civil penally LTER-DRAIN -W ATER IEA.) 5.00
of n of more than five hundred dollars($500).): '
❑ I,as owner of the property,or my employ,,,with wages as B K FLOW PROTECT. DEVICE - 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRA S-FLOOR,ROOF,AREA,COND. 5.00
Code:'rhe Contractor's License Law does not apply to uu owner nl
property who builds or improves thereon,and who does such work FIXTUR S-PER TRAP S.00 'SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such Improve-
mentsarenotintendedorofferedforsoke.If,however,the building GAS-EA.S STEM-I INC.4 OUTLETS-6.00
g or improvement is sold within one year of completion, (lie owner- GAS-'EA.SV EM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
%a. prove for purpose ofsale.l. RES IND CON' PR - Door
Cl L as owner of the property,and exclusively contracting with INDUSTRIAL W TE INTER. 30.00 ❑ ❑ ❑ ❑
licensed csions Tod In construct the project(See.7044,Business LAWN SPRINKLE -1 INC 5 V.B. 6.00 . ASSESSORS PARCEL NO.
and Professions Code:The Conlmalor's License Law Joos not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS- VER 5(EA.) 1,00
contracts for such projects with a conlructor(s)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STNM EA.200ft/10.00 TRACT NO. .PARCEL NO.
❑ I am exempt under Sec.-,B.&P.C.for Thi, WATER HEATER W/VEN 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACG.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, NN, 5.00 -
1 hereby affirm that I haven certificate of consent to self-irsum,
or a certificate Of Workers'Com pensalinn Insur:mcro,or a crfijy c,l ZONING ENG.SITE NO.
copy therlr({$P� Npp;Lab.C45,, ,,"a,r�r N(A1'\
Policy No 5 - mD.Gy_L-N V10
0 ❑ Certifiedcopyislmra by flunishi-d' FIRE SPRINK ENERGY T-24
Z Z 'q( Certified Copy Is Ile with (lie city inspection division.
H O AA, cant 4�. MISC.- REFER TO OR Y 11 N11 Y 11 Na
cc y CERT IFICA'I'E OF EXEMPTION FROM WORKFRS' PERMIT ISSUANCE - 10.00 FLOOD ZONE A.L.U.C.
LU > COMPLNSA'1'ION INSURANCE PLG.CONTR, LIC.NO. PLG.
CL O This Section need not be completed if the permit is for one TOTAL Y E_ NE) Y[] NF
Z hundred dollars($100)or less,) IK I
U O . I certify [hat in the performance of Ilse work for which this Por- GTV. MECHANICAL PERMIT FEE FEE SUMMARY
OL I- mit is issued.I shall not employ any person in any manner so as to
Q U become subject to the Worker;Compensation laws of California.
y Dote Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NO'T'ICE TO APPLICANT: II',urger making this Cctlil'ica[o of Ex-
� z empti,n,you should beton..subjecno file Workers'Compensation APPLIANCE 5.00 PLAN CHECK
U
provisions of the Labor Code, you must forthwith comply with FEE 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 10.00DC.F.M.) 6.00 , SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
file Performance of Iho work for which this pernril is issued(Sec. MICROFILM
3097,Civ.C.). , . . .
HEATING UNIT(TO 100000 BTU) .�0
Lender's Name'
Lender,Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
a r, I Cerlify That 1 have read Ihis application and state that fit,above VENTILATION FAN (SINGLE) 4.00
i dnaatibn correct.I agree is comply witl all city and county PLUMBING
orrdinances and state laws relating m building construction, and BO(LER-COMP(3 H.P.or 700,000 B.T.U.) 6.00
hereby authorize representatives Of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
TWO agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
CaYe it, a against liabirecr;ties,judgments, costs and expenses which PERMIT ISSUANCE -Op CONST.TAX
len in an wayaccrue a•uin5t said Cit in ams, uenro of the
-F2-
gra f\inJa1�\'(I t/hiiss ppeermmitt.. MECR.CONT. LIC.NO. MECH. �Ir
1Ur.Vc� 0� Q-I /yy} /t/ J�ppy�:-s ��.-s2 TOTAL/f l' B''D TOTAL
Slgigsnatoree Of Applicant/Contractor Date !,' 1 ��V CI'C.�"""h,. 14" �• O`
OFFICE COPY