6950 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATION PERMIT NUMBER
BUILDING,
APPLICATION & PERMIT
f/R:_
BUILDING-ELECTRICAL-PLUMBING.-MECHANICAL
zoRS TowH ��� Je, N 6950
2r OWNER'S PLAN CHECK VALIDATION
NAML liOTY. ELECTRIC PERMIT FEE
• I1a-I �)ej�t kZ/4.T44fJ PR0tJ E�e
c TRACTORS UTLETS-SWITCHES-RECEP 5.00/1.00
N ME ,/ QN S
E,E o5 �e�^) ^o� 6 3 7 LIGHTING FIXTURES 5.00/1.00
r.GNTr AciDR's ��� PPLIANCES-RESIDENTIAL 4.00 xv-A
ADDRESS //•�
23SSL1ar Cd' ONE (p PANELS 5.00 DATE OF APPLICATION
ARCHITECT $IGNS 6.DD PLAN CNECK FEE P.C,N0.
OR - ` r
ENGINEER
LIC.NO. rSIGNS TRANS. 3.00
nooa'Ess ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
i,P rrEMP. METER OR POLE INS. 15.00
APPLICANTS MOTORS • SEE FEE SCH.
ADDRESS
S SERVICE CHANGE 10.00
w02 LICENSIiD CONTRACTORS DECLARATION
F Z W I hereby affirm that 1 am licensed under provisions ul'Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLOC. ELECT. PLG. MECH.
Fh i professions Code,a my license is in full farce and effect.
2 o m - License Cl a Lic.Number -
o w H w Dale l_ 81f Contractor
m f j C�-I r BUILDING PERMIT
rt w o OWNER-UUILLFR DECLARA'I'ON INFORMATION
dos MISC.- REFER TO OR
w g u
_/ I hereby affirm that I am exempt from the Contractors License VALUATION E/FT.
F w o a Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSOANCE 6.00
Code:Any city or county which iequiresa permit toconslrucl,alter,
.re a,Q Q
n improve,demolish,or repair any structure,prior to its issuance,also ELEELEC.CONTR, LIC.NO. ELEC.
y O LL requires the applicant for such permit to file a,ggned statement that TOTAL a oa �' PERMIT TO
w m be is licensed pursuant to the provisions of the Contractors License
F z aLaw(Chapter 9(commencing with Section 700()o'Division3oflhe Te/Ary-N /y/}r20✓b)
fiusiness and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
r Do the basis for the alleged exemption.Any violation of Section7031.5 ' STORIES TYPE CONSTR.
to
;m by any applicant for a permit subjects the applicant(on civil penally ALTER-DRAIN -WATER (EA.) 4.00
of not mare than five hundred dollars($500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00- DCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended of offered for Site (Sec. 7044, Business and Professions DRAINS,-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License law docs not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.BO 30 FT.FLOOR AREA TOTAL ACREAGE
. himselfor through his own employees,provided that suchimprove-
meatsarcnot intended or offered for Sala ll;however,thebui[ding GAS-EA.SYSTEM-11NC.4OUTLETS 4.00
or improvement is sold within one year of completioq the owner- GAS-EASYSTEM-OVER 4(EA.IX 100 BUILDING USE
builder will have the burden of proving that he did not build or inn- .- RES IND CON PB Other
prove for porpr.m5sale.). INDUSTRIAL WASTE INTER-/ ' 20.00 El El El 1-1 1-1CI I,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. 5.00 ASSESSORS PARCEL NO.
and Professions Cude:1'he Contractor's License Law duesnot apply
to un owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 .
amtmeis for such projects with a conlmetods)licensed pursuant to
the Conamctors License Law. - SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
17 lam exempt under Sec. ,tl.&1'.C.tar this WATER HEATER W/VENT 4.00
reason
Owner Dale WATER SYSTEM 4.00 ACC.DATE ACC.`FILE NO.
WORK ERS'COMITNSA"I"ION DECLARATION WATER TREATING EQUIP. 4.00
1 hemby alllrro that I have a certificate ol'eansent In x11-in...L',
or a certificate of Workers'Compensaliun Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3900,Lab(;.).
Puri,No. Company STd.4c F»
0 ❑ Certified copy is hereby tummined. x FIRE SPRINK ENERGY T 24
Z Z u5
Certified py filed w' h the city inspe t� ion division. MISC.- REFER TO ORD. Y N Y N
p APp icanl ❑ ❑ ❑` ❑
Ir Ln C17RTIPIC 'E0 FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.uc.
W > COMPENSA'flON INSURANCE: PLG.CONTR. u LIC.NO. PLG.
EL
O (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
Z b and rcdd.IIm,(S100)orlcss.)
U O 1 certify that in the performance of Rm work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued.I shall not employ any person in any manner so as to
U become subject to the Worker:Compensation Laws of California.
0 ED Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING (Q
} m NO'T'ICE 10 APPLICANT: If,after making this Certificate of I.x-
? cnlptiun,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with - FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1OMCF.M-) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER1Q000C.F.M.) 5.00 _ SEISMIC FEE y j
1 herchy uffon that there is a ecuSIRCtlon lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work lot which this permit is issued(See. MICROFILM \
3092 Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC �a
I certify mel I lwvc read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
it Rfinarces n correct. I agree to comply with all city and wanly PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,0008.T.U,) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- • REFER TO ORD.
CUponino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3-00 �- CONST.TAX
may in any way accrue against said City in consequence of the
grant. of Otis pe nni. MECH.CONT. Y LIC.NO. MECH. ? ..
z tf o TOTAL11 TOTAL �yj�33
ignuW o Applicant/CmAmetnr Date
INSPECTOR COPY