09692 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
YAODRES
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 9 6 9121
NAME PLAN CHECK VALIDATION
\( NAME QTY. ELECTRIC PERMIT FEE
•/ PXONE
r+nrN.1e ° OUTLETS-SWITCHES-RECEP 10.00!1.00
LIGHTI NG F IXTURES 10.00/1.00
X Ao0HES5 R APPLIANCES-RESIDENTIAL 4.00
rwT vnorvE PANELS 10.00 DATE OF APPLICATION
CHITECi PLAN CHECK FEE P.C.NO.
on PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.No�-tl' SIGNS TRANS. 3.00
ARCHORErvG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 �f
APPLICANT
S SCH.MOTORS SEE FEE r•„_, _r/, �_/
ADDRESS
SERVICE CHANGE 20.00
re 0 = TEMP.POLE 30.00
re O LICENSED CON'I'RACT'UHS DECLARATION
a u o 1 hereby iffnn that I are licensed under provisions of Chapter 9 1 ISSUANCE DATE
H G w (conunrncing with Section]000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F m z Professions a d use is N full for • n ff 1:1
❑ ❑
M-
Z O v, License la Lic-Number
0 w Da[e Contractor
4 y E J
¢ ¢ re st OWNER-BUILDER DECLARATION
F.
BUILDING PERMIT
o a " MISC.- REFER TO ORD INFORMATION
3 r I hereby affirm that I am exempt from the Contractor's License w
H LL O Law liv the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE VALUATION $/FT.
o ln � Code:Any city orcounty which requinsa pennd toconsOuct,alter, 10.00
a v( improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
Q requires the applicant for such permit to file a signed statement that TOTAL
u w Rm he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
HZQ Law(Clmpler9(conamencing with Section 7000)of Division 3of file',
PLgG
4 D Business and Professions Code)or[hal he is exempt therefrom and' QTY. PLUMBING PERMIT FEE
re I m the basis for lite alleged exemption,Any violation of Section 7031.5 STORIES TYPE CONSTR.
a3 _ by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(8500).):
❑ I,as..net 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 s ructure Is not
intended or offered for sale (Sec. 7044, Business and ProfessionsDRAINS-FLOOR,ROOF,AR EA,COND. 5.00 tlL
Code:'FIm Conlmctor's Liccnsc Law does not apply to an owner of
property who builds or improves thereon,and who does such work F IXTURES-PER TRAP 5.00 lfb �- SQ FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improvc-
meatsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS EASYSTEM OVER 4(EA) I' 2.00
builder will have the burden of proving that h - . - .
e did not build or im- BUILDING USE
Prove for purpose of sale'). INDUSTRIAL WASTE INTER3000 RES IND CON PB Orhe,
❑ I,as owner of the property,am exclusively contracting with . .
El ❑ ElED 1:1licensed contractors to construct the project(Sec, 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 600 ASSESSORS PARCEL No.
and Professions Code:The Contractor's License Law docs not apply .
to an owner of property who builds or improves thereon.and who LAWN SPR IN KLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractorls)licensed pursuant to
the C'ontractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ l am exempt under Sec,-,11.&RC.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPIiNSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent toself-insure,
or a Certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(See,3800,Lab.C.).
Policy No. Company Wa'S�?A) C/g7�J
0 ❑ Certified co y Iv I Creby furnished. FIRE SPR INK ENERGY RZ4
z z, `�Cerlifie X0�1 I filed with the city inspection division. ❑ ❑ ❑ ❑
Applicant U��%/ �, MISC.- REFER TO ORD. v N v N
CCN CERTIFICATE OF EXENIPI'ION FROM WORKERS' PERMIT ISSUANCE 10.00 -- FLOOD ZONE AL.0
L COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
Z (a. This action need not he completed if the permit is for one TOTAL /�fN Y❑ N❑ Y ❑ N❑
V O hundred dollars($100)orlc,,)
I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
L 1- mit is issued,I shall not employ any person in any manner so as to
U becomesuhject to the Workers'Compensation Lawsof Culifomin.
a [)arc Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ N 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
such
of the Labor Code, you must forthwith comply with
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the perkaromnee of the work for which this permit is issued(Sec. MICROFILM
3097,Civ,CJ, HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state Iha[the above VENTILATION FAN (SINGLE) 4.00 /rys
•
information n estate l I agree to comply withal]city and county BOILER-COMP 13 H.P.or 100,000 B.T.U.) 6.00 PLUMBING �(�
ordinances and state laws relating to building construction, and
hereby authorise representatives of on city to ewer upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
hereby
mentionad properly forinsp ofth i putty to.
(We) agree.to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
CnPenmo aganst Iiabillpes,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in a w 31 a" at against said City in consequence of the
granting 6f this pI 11i1. , MECH.CONT. LIC.N0. MECH.
OTAL
Sign faro ppb'ant/Contractor I he
TOTAL
INSPECTOR COPY