8235 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDROSSA
O N BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 8235
OWN 'S F PLAN CHECK VALIDATION
• NAMEvHo y
V 190 CITY] ELECTRIC PERMIT FEE
tNAME CTOR's UTLETS-SWITCHES-RECEP 10.00/1.00
NAME ,Q. ��7�/
�// L1.2, /C/(� LIGHTING FIXTURES 10.00/1t00
TIoNTRACTOR's / APPLIANCES RESIDENTIAL 4.00
AoD s
N PANELS 10.00 )
DATE K APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE PC,NO.
on
ENGINEER
LIc.No, SIGNS TRANS. 3.00
moo ESS Erva. SPECIAL CIRCUIT 5.00 } PERMIT VALIDATION
ZIP rrEMP. METER OR POLE INS. 20.00
APPLICANT'S MOTORS SEE FEE SCH.
(SF eA
A $
SERVICE CHANGE 20.00
Doo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 ,
a u I hereby affirm that 1 am licensed under provisions of Chapter 9 g� ISSUANCE DATE 1
H < m (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F y z Professions Code,anA m license is in full kI and cIT t. ❑ ❑
z o w- License Class Lic.Itumhcr
Et z r o Late Convector
a Y E BUILDING PERMIT '
¢ m w a OWNER-BUILDER DECLARATION INFORMATION
R O a U MISC.- REFER TO ORD
w S u I hereby collo that I am exempt from the COntmctorr License VALUATION
a_ Law Law for the following reason(See.7031.5,Nusinessund Professions PERMIT ISSUANCE 10.00 -
Code:Anycity orcounty which requires a permit to construct,alter,
4 0O improve,demolish,or repair any structure,prior W its issuance,also ELEC.CONTE. LIC.NO. ELEC.
an d c ¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n
to to he is licensed pursuant to lite provisions of the Contr.Ietor's License ,
Fz i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe {�S/
a Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE I'/li
¢ Ho the basis for the alleged exemption.Any violation ofilection 7031.5 STORIES TYPE C NSTR,
a3 _ by any applicant for a permit subjects the applicant tot civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).0
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 ptit
their sole compensation,will do lire work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS- EA N 5.00
Code. The Contractor's License Law docs not apply to to owner of
property who builds Or improves thereon,and who floes Stich work FIXTURES- R AP 5.00 50.FT.FLOOR AREA TOTALACREAGE
• himself epts re through his own,mpld for sale.if,H that such int Drove
mmselfo not hroughto, or empld ee.... if, that suhc buildingGAS-EA.SYSTEM-11NC.4OUTLETS 8.00
Lost or improvement is sold within one year of completion,the oner - . .) 2.00- GAS EASYSTEM-OVER 4 (EA
builder.will have the burden of proving that he did not build or int- BUILDING USE
prove for purpose of sale.). I
INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB other
❑ I,as owner of the properly,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
IICCnWd 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 does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 MA.) 1.00
contracts for such projects with a contractons)licensed pursuant to SEWER-JXNITAR ORM A.200ft/1000
fire Contractors License Law. TRACT NO. PARCEL NO.
❑ [am exempt Linder SeC. B.&P.C.for this WATER
on
Owncr Date f WATER SYSTEM 5,00 faVb ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby aDinn that I have a eertilicme of consent m self-insrha-, ZONING ENG.SITE NO.
or a curtifictte of Workers'Comp, "tion Insu a Le,ora citified
cll1*10r(gg�c.38 aKC
.
cpyP11" niic oismpabnyy
❑
FIRE SPRINK ENERGY T 2 `.
Z 2 ❑ Certified cPtpy is filed wi^ 4re^city inxpeaion division. MISC.- REFER TO ORD. }. N v N
O r tl ream ,I ❑ ❑ ❑ ❑
ir T CER'IIFI ATF- IIF M WORKERS' PERMIT ISSUANCE 10.00 K FLOOD ZONE aL.uL.
LL > COMPENSATION INSURANCE PEG.CONTE. uC.NO. PLG.
CL Z CI'his section need not be completed if lire permit is for one TOTALVff Y ElN❑ Y E] N[3
hundred dollars(S 1001 or less.)
U O 1 certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
UL b- mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compemnlion Laws of California.
ED Dale Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE'FO APPLICANT: If,after making this Certificate of Fx-
j Z cnmlion,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith cmnply with FEE
C) such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT .) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10 C.F.M.) 6. 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,C.v.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,00013.T.U.)9.50 '
Lender's Address HEATING
1 certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
S infannation is correct. I agree to comply with all city and county ,... PLUMBING
ordinances and state laws relating-to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) BOB. 1Q V%
hereby authorize representatives of this city to enter upon the BOILER-COMP IOver 100,000 BTU)SEE FEE SCM. MECHANI C/}L J
above-mentioned property for insp,ction Purposas. /4/ S
"ot
t save, indemnify and keep harmless Inc City of MISC.- . REFER TO ORD.
liabilities,judgments, costa and a pnuea which PERMIT ISSUANCE CONST.TAX
t Bccrre against said Cily incons,luence of lire'TinMECH.CONT. LIC.NO. MECH,8564 J TOTALp icaut/Contractor I7 to
W
INSPECTOR COPY
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