4086 APPLICANT TO FILL IN INFORMATION WITH•IN RED LINES - USE BALL POINT PEN ONLY
,PERMITNUMBER
- BUILDING PROJECT IDENTI FICATION � -
BDILoINc APPLICATION & PERMIT
ADDRESsgi'0730 '✓Ht-•f-C-x( ' LI'RE �Q• V '4086
• BUILDING-ELECTRICAL-PLUMBING-MECHANICAL ,
OWNER'S - - - ---- ----------- -- - -- PLAN CHECK VALIDATION
NAME ACQfAAS QTY. ELECTRIC PERMIT FEE
PHONE .��p
CONTRACTORS p OUTLETS-SWI RECEP 5.00/1.00 J '4
HAIQ 2.LEcI RI C- _lC.No. IO2.� Z LIGHTING FIXTURES 5.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADORESsp w' q.. pn g�� _ rT' qq
'j7LG Ppl6t.9l7e�r1. 7f)N1(Lt-wsft JlrC C) PANELS. - 5.00 DATE OF APPLICATION
ARCHITECTSIGN$ - 6.00 PLAN CHECK FEE G.NO.
OR
ENGINEER
LIC.NO SIGNS TRANS.. 3.00
ADDRESS ENc' SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS 376 P/
/Ne'.wD 4
p SERVICECHAGE 10.0 3w00 LICENSEDCONIRACIORS DECLARATION JL p
a o u I hereby affirm that I am Iicnnsd! under provisions of Chapter 9 ISSUANCE DATE
yQ n (commencing with Section 70 0)of Division 3.1 the Entire;anJ BLDG. ELECT. PLC. MECH.
F m z Professions Cod and y license it in lull for5e and e��ey ❑ ❑
Zion - Licenu lass Lw,Number4 10 9- /Z� RJ
O r w Date�Conlmctof Cr a�T
a y s ' _I /c -•I 3- g -5 -BUILDING PERMIT
¢ ¢ w u OW'N Ii R-B UI LD I7R DECLARA'T'ION
w3 LL y I hereby affirm that 1 am exempt from the Contractors License MISC.- AUG I TO ORD INFORMATION
uOv, Law for the following moon.,(Sec.7031.5,Businasand Professions PERM IT ISSUANCE VALUATION $)FT.
Code:An cit orcount which re uiresu 6.00
y y, y y permit to construct col«q
¢ < FO improve,demolish,or repair any structure,prior to its issuance.also ELEC.CONTR: EC.
ei
o ¢ requires the applicant for such permit to file a signed statement that TOTAL 041 6 ..1 PERMIT TO
wm he is licensed pursuant to the provisions of tiro Contmclor's License
HzA Law(Chapter 9(commencing with Section 7000)of Division 3 of the CL.6Z�
a Business and Professions Code)or flat he is exempt therefrom and OTV. PLUMBING PERMIT FEE
¢ r o the basis for the alleged exemption.Any violation of Segion 7031.5 STORIES TYPE CONSTR.
aa
;�. by any applicant for a permit subjectsthe applicant ton civil penally ALTER-DRAIN&VENT-WATER IEA.) 4.00
of not mon,than Five hundred dollars($5004):'
❑ 1,as owner of the property,or illy enlployces with wages as BACK F LOW PROTECT. DEV ICE 2.00 OCC,GROUP RES,UNITS
their sole cowe
mpensation, ll do the work,and the struma;Is not.
intended or offered for sole ISS;. 7044: Nosiness and'Protroions DRAINS-FLOOR,ROOF,AR EA COND. 4.00
Code:The Contractor's License Law dos not apply to un owner of -
properly who builds Or improves Thereon,and who doff such work FIXTURES-PER TRAP - 4.00 Sa FT.FLOOR AREA TOTAL ACREAGE
mentslf re Through his own fferedf•os,provided that such improve-
menti are not u,h ,is or alfa;.tie tole.IL however,the nuilding GAS-EA.SYSTEM-1 INCA OUTLETS 4.00
or improvement is sold within one year of coniplelion,the owner. GAS-EASYSTEM-OVER 4 (EA) 100 BUILDING USE
builder will have the burden of prnving)hu1 he did not haild or r . . i.
GO RES tND CON PB Omer
prove for purpose of sine.). INDUSTRIAL WASTE INTER. 20.00
-❑ rope
1,us Owner OI the properly,ant exclusively coittructing with ❑ ❑ ❑ ❑ ❑
licensed contractors tO.aonstruct the project(Sec. 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's LicenA,Law dues not apply
to as owner.1 property who builds or improves thercon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a cimamclons)Incilwd pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM 'EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. .N.kP,C.I'nr this WATER HEATER W/VENT 4,00
reason
Date _ Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK E RS'COMPENSATION DECEkRATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a cenificateofconsent to wING...ru', ZONING ENG.SITE NO.
or a certificate of
Workers'Compensation Insurance.or a certified
copy thereof(Sec.3900,Lah,C.).
Policy No. Company _
❑ Certified copy is hereby famished. FIRE SPRINK ENERGY T-24
z'Z ❑ Certified copy is fled with the city inspection division. MISC.- REFER TO ORD.
O Applicant v❑ N❑ V [:] No
CC rn CERTIFICATE OI°EXEMPTION FROM WORK ERS' •PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU >' COMPENSATION INSURANCE PLG.CONTR. - LIC NO. PLG. Y N V N
(This section need not he car lot if the permit is for One - TOTAL ❑ ❑ ❑ ❑
� Z hundred dollars(S 100)or kss.l
_V O 1 certify that in the perfommm a the war fO wh' h this,per- QTY_ MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued, shall not employ perwn i n was to
U been bj the or em IO til Hara.
Q Dat_Applicant cg BUILDING
a ALTER OR ADD TO MECH. - - 4.00
} to NOT E O APPLICANT: It,aft r making this CertiFicate of Ex-
F 2 mption,you should become subject to the Workers Compensation APPLIANCE 4.00 PLAN CHECK
promit visions of the Labor Cale, you must forthwith comply with FEE
U such provisions or this pershall be deemed revoked. - AIR HANDLING UNIT(TO IOpC
OOF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10900CF.NL) 5.00 SEISMIC FEE
I hereby affirm that there is a ;construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00 4
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.1. HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lendeh Name y
Lender's AddrtG HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC J �p
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.DO '
.information is correct. I agree t0 comply with all city and uumty PLUMBING
Aordinances and state laws relating to building consiructum, and BOILER-COMi H.P.or 100,000B.T.U.) 4.00
herc inentinned roperty for inspection urpows. Over authorize repo.tative, this city enter upon the BOILER-COMP Br 000,000 BTU)SEE FEE SCH MECHANICAL
abre pp
(We tins,
rove, indemnify and keep harmles.v Ihe'City col' MISC.- REFER TO ORD.
Co"'II agains0 liabilities,jud y t'nts, cosi,and expenses which - CONST.TAX
may any way a to igainaI id City in cense uu I Ihu PERMIT ISSUANCE 3.00
grw gal lhix IN t - MECH.CONT, LIC.NO. MECH.
TOTAL TOTAL
Sign rcof Applicun 1"nn moor Um• -
- OFFICE COPY