12069 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT,PEN ONLY
.BUI LDI NG PROJECT I DENTI.FICATION - PERMIT NUMBER
it LDING ' APPLICATION &PERMIT-
ADDRESS12 69
I G b
km &tBUILDING=.ELECTRICAL-PLUMBING,-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
'NAME ^^rr..���E'ppP'••��11 +1 - ELECTRIC PERMIT FEE
PR.
NAMECONTC s /.'�\1 OUTLETS-SWITCHES•RECEP ' 10.00/1.00
NAME \ .. 1�V %1\J
IC.No LIGHTING FIXTURES 10.00/1.00
FONTRAcrDR' PPLIANC ES-RESIDENTIAL 4.00 . -
ADoN
.t
NELS 10.00 DATE OF APR LICATION
ARCHITECT PANELS (OVER ZOO AMP) 20,00 PLAN CHECK FEE P.C.NO. `
OR
ENGINEER
LIC.NO. SIGNS TRANS: •3.00 _
ARCH,OR ENG.
ADDRESS SPECIAL CIRCUIT 'S,OO • - .PERMIT VALIDATION
.r-
_
ZIP - EMP.METER OR POLE INS. 20.00 "
- •
APPLICRESS ANT'S
ADD
MOTORS - - SEE FEE SCH. A
`y
` - SERVICE CHANGE 20.00 �O
M
02, LICENSED CONTRACTORS DECLARATION /ry^Q
Ie u H . I hereb affirm that I arm licensed under provisions of Chapter 9 ° "� ISSUAnfL'f F7 E
¢z w Y P P
(commencing with Section 70001 of Division 3 the Business a ECT. L MECH.
G ,n O Prolessions CoA n t •nse is in'full force' a t. n,^11
i N o License Class-
0ic.Number _ 1 _ - ❑ n ❑
w H
Date Contractor_
- -
¢ �� w✓ BUILDING PERMIT
¢ ¢LL ¢ - OWNER- U UER DECLARAT N INFORMATION
- o a D REFER TO ORD
w-; u y 1herebyftire
affirm ing I am exempt from the Business and
license MISC.- .
Imo ¢ Law for um following reason.(Sec.703L5,BusinessanJProfessions PERMIT ISSUANCE 10.00 , VALUATION, $/FT.
� - -' Cade:Any city or county which requiresa permit towns[ruct,alter,
ce ¢ ¢'Q improve,demolish;or repair any Struclum,prior to its issuance,also ELEC.CONTE. LIG.N0. ELEC.
- DLL requires the applicant for such permit to file a signed statement that TOTAL P IT '0
u w $ he is licensed pursuant to,the provisions of the Contractor's License
zi
Law(Chapter 9(commencingwith Section 7000)of Division3 of0m "
4 ¢o Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
fL 1- p the basis for droalleged exemption.Any violation of Section 7031.5 - STORIES YPE C N'TR.
n ; by any applicant for a pemin subjects the applicant ton civil penalty gLTER-DRAIN& VENT-WATER (EA.) 5.00 c
of not more than five hundred ned dollars(SSOO):):
❑, I,as owner of the property,or my employees with wages as BACK FLOW PROTECT:DEVICE - 4.00
their sole compensation,will do the work,and the structure is not o. GROUP RES.UTS
intended Or offered for sale (Sec. 7044, Business sand Professions - DRAINS-FLOOR:ROOF,AREA,COND. 5.00
Code:The Contractor's License haw does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP - - 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
rnmdsmv,Rot intended confuted for sale.If,huweveq the building, GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM,-OVER'4 IEA.) 2.00 BUILDING USE
builder will have.the burden of proving that he did not build or im- - R S IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE'INTERi 30.00
❑ 1,as ownerof the property,am exclusively contracting with ❑' ❑ ❑
licensed contractors to construct the project IS".7044,Business LAWN SPRINKLERS- 1 INC 5 V.8. 6.00 A ESSORSPARCELNO.
and Professions Codc: rhe Contractor's License Law docs not apply -
to an owner or property who builds Or improves thereon,and who LAWN SPRINKLERS OVER 5 IEA.) 1.00 ,
contracts fur such projects with a contractors)licensed pursuant In $EWER-SANITARY-STORM EA.200ff/10.00
the Contractor's License Law. RACT NO. - - PARCELNO.
❑ 1 um exempt under Sec. B.&P.C.lot this WATER HEATER W/VENT 6.00
reason
10,90
Owner Laic WATER SYSTEM 5.00 .
ACC.DATE ACG FILE NO.
WORKERS'COMPENSATION UECLARAIION WATER TREATING EQUIP,- 5.00
I hereby afOrm that I hove a ceniftcale ofconsent to self-insure, - ZONING or acerlificale O W r ml cnsefor 1 uun e r a cerlif-d ENG.SITE NO.
copy t e f a .a.J. - -
Policy I -
C) : ❑ 'e Ie 'Opy L' e b ( niche - FIRESPRINK ENERGYT-24
Z Z ❑ erli 'opy 's fi d th the city inspection Jivisiom MISC.- REFER TO ORD.
Q .A' i, \ Y ❑ N❑ V ❑ N❑
� N •CIiUTIFA'1'IiOF F,XEh11'TION f°Rohl WORKERS' PERMIT ISSUANCE 10.00 FLooO ZOrvE A.L.uc.
.W COMPENSATION INSURANCE ' PLG.CONTE. LIC.NO. .PLG 'd (This sneed not be completed if the permit is for one ' TOTAL Y❑ N❑ Y❑ N❑
Z hundred DIISRS(S 100)or less.) - -
L) O I certify that in lire performance of the woik for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY ,
IL I- mit is issued,I shall not employ any person in any manner so as to
V become object m lira Worker,'Com nolion Laws of Callf.m.
a Ed Dale ICL Applicant - Fe ALTER OR ADD TO MECH. 5.00 BUILDING
} t4 NOTICE TO APPLICANT: If,after making this Certificate of lix-
H ? emption,you should huconm subject to the Wurkeis:Compensation APPLIANCE `5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith com Ply with FEE
U suchprovisions oothis permit shall be deemed revoked AIR HANDLING UNIT(TO 10=C,F.M.) 4.00
CONSTRUCTION L17NDING 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 perfcrmance'of the work for'which.this permit is issued(Sec. HEATING UNIT ITO 100,000 B.T.U.) 8.00 MICROFILM
3097,Cw.C.).
Leader's Name - HEATING UNIT(OV ER 100,000 B.T.U_ .)9.50 ELECTRIC t
Lender's Ad dress
I certify that I have iead this application and state that the above VENTILATION FAN (SINGLE) . .4.00
information is correct.I agree to comply with all city and county - .PLUMBING t
ordinances and state laws relating to building construction, and BOILER-ODMP(3 H.P.o-100,000B.T.U.) '6.00
Hereby authorize.represenlulives of this city(to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE'FEE SCH. MECHANICAL I
(We) agree to save, indemnify and keep brimless the City of MISC. REFER TO ORD. -
Cu ertimo against liabilities,judgments, costs'and expenses whichCONST.TAX ..
- a in any w 4crue against said City in consequence Of the PERMIT IS LANCE - 10.00
1,antg of t Is t .CON LIC.NO, MECH,
- rorno'`' TOTAL
Sia re ofA plicanl/Con lro r, Dare -
'OFFICE COPY -