C8175 AP�l II.CANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION - PERMIT NUMBER
aDILDIrvG -T t APPLICATION & PERMIT
�L AOORESS ®LW PN' /�
B51LDING-ELECTRICAL-PLUMBING-MECHANICAL-_._. % 8175
OWNE 'S PLAN CHECK VALIDATION
� ) NAM vHorvE DTV. ELECTRIC PERMIT FEE �l y S "/"^^ j
CONT acro OUTLETS-SWITCHES-RECEP 10.00/1.00 l (/
NAME
LIC.NO. LIGHTING FIXTURES 10.00/1.00
7oN7RAc7oRs PPLIANCES-RESIDENTIAL 4.00
t ADOREss
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 �� PLAN CNECK FEE P.C.NO.
Ofl
ENGINEER
' I.C.No. SIGNS TRANS. 3.00
AARCH OR DDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP. METER OR POLE INS. 20.00
Arvrs MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
i>u I hereby affirm that 1 am licensed under provisions of Chapter 9 1 ISSUANCE/DATE
N G , (commencing with Section 7000)of Division 3 of the Rosiness and BLDG. ELECT. PLG. ,MECH.
H m z Professions Code,and my license is in full force and affect. ❑ ❑ ❑
z 0 w - License.Class Lic.Number
0 - Date Contractor
u,H
a m E BUILDING PERMIT
ac a, w ¢ OWNER-BUILDER DECLARATION° INFORMATION
wD a ° �• MISC.- REFER TO ORD
u 1 hereby al firm that I am exempt from the Contractor's License VALUATION
Fa04 Law forthe following reason.(See.7031.5.Business and Professions PERMIT ISSUANCE 10.00 /
Code:Any city or county which requires a permit to construct,alter,
¢ a a 2 improve,demolish,or repair any structure,prior to its issuunce,also ELEC.CONTE. LIC,NQ ELEC. ✓
ar
- DLL requires the applicant for such permit to file a signed statement that TOTAL PERMIT T <
cm he is licensed pursuant to the provisions of the Contractor's License
Hsi Law(Chapter 9(commencing with Section 7000)ofInvision 3 ofthe /.k/+jcrQrUQ 7�-NIV/}�•L.
¢ Business and professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Section 7031.5 W STORIES TYPE CONSTR.
per _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and ProfessionsDRAINS-FLOOR,ROOF,AREA,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 FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
- himself or through his own employees,provided that such improve.
mems are not intended or offered for sale.If.howeveq the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 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 int. RES IND CON PB Other
Drove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 El ❑ El 1:1 1:1❑ 1,as owner of the property,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:Tim Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for sh-projects with a contructons)licensed pursuant to
the Contract Li'nu La SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ 1;r(ext, / Do . ,2. .BAP.C.for this WATER HEATER W/VENT 6.00
reason
>C
One4%,4Ds - WATER SYSTEM 5.00
ACC.GATE ACC.FILE N0.
AID :. .1PI3NSAT N DECLARATION WATER TREATING EQUIP. 5.00
I hereby;if firm flim ]As,,a Xt first,of consent to self-insure. ZONING
or a certificate of Work r C pensation Insurance,or a certified _ ENG.SITE NO.
copy thereof(Sec.380Q )- ('
Policy No. Company
O ❑ Certified copy is hereby furnished, FIRE SPRINK ENERGY T-24
Z_ Z ❑ Certified copy is fled with the city inspection division. MISC.- REFER TO ORD.
O Applicant ' Y ❑ N❑ Y ❑ N❑
~ mc.
LU CIiRTIf°KATEE EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.0
' W > COMPENSATION INSURANCE PLG.CONTE. LIC.No. PLG.
CL O (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
D Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H Ioil is issued,I shall not employ any person in any intoner so as to
become subject to the Workers'Compensation Laws of California.
O w BUILDING
n Dat, Applicant ALTER OR ADD TO MECH. 5.00
} W NOTICE TO APPLICANT: If,after making this Certificate of Fs-
Z emotion,you should income subject it,the Workers•Compensation APPLIANCE 5.00 PLAN CHECK
Provisions of the Labor Code, you must forthwith comply with FEE
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10J100C.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000GEM.) 6.00 SEISMIC FEE LF `
I hereby affirm that there is a scommctinn lending agency lit. EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Name ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agiee to comply with all city and county PLUMBING .
mdimoses and slate iaws relating to building construction, and BOILER-COMPI3 H.P.or 100,0008.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL t
abovc-mentumed property for inspection purposes.
rIl,4H✓egind to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
erhim against liabilities,in gm ms, Cost, and expenses which CONST.TAX
may In anjx way ac Ge agar City in consequence of the PERMIT ISSUANCE 10.00 ,rt
gran 'ngof t- ed. MECH.CONT. LIC.NO. MECH.
_ TOTAL CF
TOTAL y �
igna u t/Cmulacmr Date -
INSPECTOR COPY