11512 (2) 'APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-- USE BALL POINT PEN ONLY
BUILDING PROJ ENTI FI ION PERMIT NUMBER
BD4 cn G / C1�Ci,�.F1GGTRICAL-
APPLICATION & PERMIT
PLUMBING-MECHANICAL 11512
\tet
OWNE PLAN CHECK VALIDATION
NAME � ELECTRIC PERMIT FEE
�(f' vHON
cD r a R' UTLETS-SWITCHES-RECEP 10.00/1.00
NAM
LIC.ND, LIGHTING FIXTURES 10.00/1.00
O°NT 's APPLIANCES-RESIDENTIAL 4,00
' woo
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITE PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE .C.NO.
OR
ENGIN
sec.iso SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADOHESs
LP EMP.METER OR POLE INS. 20.00 Y • -
Ars
aDDRESSoREss - MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
0 0 o LICENSED CONTRACTORS DECLARATION I'��ff
a U w I hereby affirm (hat I am licensed under provisions of Chapter qqq//I �v116SUANCryry
E99 I
n < m (commencing wll Sec on 7000)of Division WN BLDG. ELECT. PLG. MECH.
0 z ProfessionsCal canis is in fullforcz O'�, — Llcenx(- Lic.Nem,,DatcmmBUILDING PERMIT
iOWN. UILDER DECLARAINFORMATION
w y I hereb affirm that I am exem t from the Contractor's License MISC.- REFER TO ORD
Y P VALUATION S/FT.
'F .. oj Law for the following reason.(Sec.7031.5,Business Professions PERMIT ISSUANCE D I
Code:Any city or county which requires a permit to construct,alter, �1
Q Q a p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. 'V
ELE .
- DLL requires the applicant for such permit to file a signed statement that t�fyuT TO
E
he u licensed pursuant to the provisions of the Contractors License 1{.('
F z r Law(Chapter 9(commencing with Section 7000)of Division 3 ofthc
•[ Bus ness and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FE�rll..11E 7
the basis for the alleged exemption.Any violation of Section 7031.5
TYPE CONSTR.
a by any applicant for a permit subjects the avvphcant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) e; I
of not more than five hundred dollars(S50 L): J
Cl 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
n
their sole compensation,will do the work,and the structure is not
Ixnded or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREq COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00
himself or through his own employees,provided that such improve-
ments AREA are not intended or olfertd for sale.If,however,the building GAS-EA.SYSTEM-1'INC.4OUTLETS 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 not build or im. RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of the properly,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law don 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)licensed pursuant to
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
O lam exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.D0
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby a rm that I have a centiB a of conxm to Ginwre, ZONING
or a certff of r 'Compen nee, a 'fed ENG.SITE NO.
copy t .C.).
Pricy
O ❑ er(if dcopy is chy fur s FIRE SPRINK ENERGY T 24
Z p A I CLrtilied cup led ant — i inspecion division. MISC.- REFER TO ORD. v❑ N❑ v ❑ N❑
~ w •••� PERMIT ISSUANCE 10.00 FLOOD ZONE ' A.LU.C.
LU CERTI FICA :PE EXEMPT M FROM WORKERS'
tL COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. v❑ N❑ Y❑ N❑
EL Z (This action need not be completed if the permit is for one TOTAL
hundred dollars(S 100)or less.)
U O I certify that in the performance of the work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
0 d Datc Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F 2 emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this Pcrunt shall be deemed revoked AIR HANDLING UNIT(TO 10=C.F.M,) 4.00
CONSTRUCTION LENDING AGENCY. AIR HANDLING UNIT(OVER IO,00DC.EM,) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.D0
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
XI
v Lender's Name HEATING UNIT(OVER 100,000B.T.U.)9.50
/�•y Lenders Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and countyUMBING
mminances and state laws mWing to building construction, and BOILER-CONP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
�\ BOILER-COMP Ipser 100.000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned pro y for inspection purposes.
(We) air e, ndemnify and keep harmless the City of MISC.- REFER TO ORD.
Cu parts t 'P -sties,judlpnents, costs and expenses which NST.TAX
may any/ ore against said City m consequcna of th PERMIT ISS ANCE 10.00
gran Pthis IL I/�y MEC ONT. LIC.NO. MECH.
Or TOTAL TOTAL
5 el o(Applicenl/Contractor Date
OFFICE x PY