6788 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON i PERMIT NUMBER
BUILDING - APPLICATION & PERMIT
ADDRESS
- BUILDING -ELECTRICAL-PLUMBING-MECHANICAL . 6788
EE
'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
. ONE
ONTRACTO s
NAME UTLETS-SWITCHES-RECEP 5.00/1.00
LIC.No LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
ADDHE55
WInPRONE PANELS 5.00 DATE OF APPLICATION
A E SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC,No. SIGNS TRANS. 3.00
AARCH.OR DDRESS ENG. SPECIAL CIRCUIT 5.0Q PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
ADORESSrvr's
ADDRE5 L )n O MOTORS SEE FEE SCH. J
S `�„ C-
SERVICE CHANGE 10.00
Woo LICENSED CONTRACTORS DECLARATION 7
u u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w¢N (commencing with Section 7000)of Division 3 of(be Business and BLDG. ELECT. PLG. ECEI
H h at Professions CodWLseisinfullf2.0•m- Licensa ClassLe.Nuin ww Uate BUILDINGPERMIT
Q w DER DECLA A I N INFORMATION
w3 n y I hereby affirm that I am exempt from the Contractor i License MISC.- REFER TO ORD
LL o ¢ Law far the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE VALUATION
_ 6.00
at Code:Any city or county which requires permit to construct,alter,
Be a a Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
Leu requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w m he is licensed pormeml to the provisions of the Contractor's License
Hi
Law(Chapter 9(commencing with Section 7000)o(Division 3 ofthe
Q
4 er Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
H p the basis for the alleged exemption.Any violation ofSeclion 703 L5 STORIES .TYPE CONSTR.
u3m by any applicant for a permit subjects the applicant o a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(5500).):
❑ 1,as owner of th prop•ty,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole Co. - do wil o the ork,and the structure is not
' intended or offered for 1 'ce. 4, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND- 4.00
Code:The Contra tot's i a does not apply to an owner of
property who or r ves thereon,and who does such work FIXTURES-PER TRAP 4.00 511FT.FLOORAREA TOTALACREAGE
• himself or thio gh is o n mployees,provided that such improve-
ments are tet offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 4.00
or improvement is old thin one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the bur 'n of proving that he did not build or im-
provefor purpose ofsale.). INDUSTRIAL WASTE INTER. 20.00 RES IND CON PE Omer
❑ I,as owner of the property,nm exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 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(EA.) 1.00
contracts for such projects with a conlractods)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Dale WATER SYSTEM 4.00 ACC.DATE ACG FILE NO.
WORKI:RS'COMPHNSA'TION DECLARATION WATER TREATING EQUIP. 4-00
1 hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'C pensalion I sura ce,or a certified
00,La
P
O rtllied ' IJ,c, fur,+she . FIRESPRINK ENERGY T 24
Z Z CA Ibe s Glc w lh a city inspection d' i on.
f- O nt MISC.- REFER TO ORD. v ❑ N❑ v ❑ N❑
CC N CIiRT PI .. 4 ON FROM WORKERS' PERMIT ISSUANCE 6.00 FLOODZONE A.L.U.C.
LU > ful
MPENSATION INSURANCE: PLG,CONTR. C.NO. PLG.
CL 0 (Phis section not be completed if the permit is for one TOTAL Y❑ N❑ Y [:] N❑
hundred dollars(S 100)or less.l
n U O 1 certify that in the performance f the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mil is issued,I shall not 'R ploy any person in any manner so as to
U become subject 10 the W ke Com enation Laws of California.
�,0. Date ppli ALTER OR ADD TO MECH. 4.00 0 BUILDING
;} y N(1fl Cli '1'O AIT I AN - making this Ccrlificato of lix-
(_. ? emption,you sh cul eco x subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
y provisions f b ode, you must forthwith comply with FEE
s( U such provisi s-lh s pe it shall be deemed revoked. AIR HANDLING UNIT(TO 10MCF.M.) 3.00
CONST RUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm Owl there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name H EATI NG UNIT(OVER 100,000 B.T.U.P.50
Lender's Address ELECTRIC
I certify that I haveyy a 's' plication and stale that the above VENTILATION FAN (SINGLE) 3.00
• infi+rmation is correla"I e tee It,comply with all city and county PLUMBING
ordinances and slate laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the �r
abo4�c,
d property'for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
( to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
CapWtb es,juJ cots, casts and expenses whichCONST.TAX
rycin id City in consequence of thePERMIT ISSUANCE �'jj?00ranMECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
I alar Y L t lr )ate
INSPECTOR COPY