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14413 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES = USE BALL POINT PEN ONLY BU I LDING PROJECT I DENTI FICATION - PERMIT NUMBER BUILDING"- APPLICATION & PERMIT 1441 4 43 1 ADDRESS I I J BUILDING-ELECTRICAL-PLUMBING-MECHANICAL OWNER'S IrV r NAq��� �I� PLAN CHECK V�pIOATION '- �c- iN•SV�+4I3/alrE _��� QTV. ELECTRIC PERMIT FEE NAMER"cions UTLETS-SWITCHES-RECEP 10.00/1.00 LIC No. LIGHTING FIXTURES -10.00/1.00 d� ` AnDRESsions PPLIANCES-RESIDENTIAL 4.00 ' PHONE PANELS 10.00 DATE OF APPLICATION ARCHrtECi oR p AJPANELS (OVER 200 AMP) - 20.00 PLAN CHECK FEE P.C.NO. . ENGINEER uc.No. SIGNS TRANS. 3.00 AHCH.OR ENG. PERMIT VALIDATION AGOR � Ess SPECIAL CIRCUIT 5.00 GIQIPEMP.METER OR.POLE INS. 20.00 aooe ssis - MOTORS SEE FEE SCH. D - e. SERVICE CHANGE 20.00 o 0 oLICENSED CONTRACTORS DECLARATION A n a lav 1 hereby affirm that 1 am licensed tinder provisions of Chapter 9 I H' ' H G T (commencing with Section 70001 Gf Division 3 of the Business and ISSUANCE GATE y z Professions Code,and my license is in full force and effect r -1 `e DG= jEL PLG. MECH' O 0 w O License Class Lic.Number- Date umber rViDate Contractor A'N v w er OWNER-BUILDER DECLARATION BUILDING PERMIT X 3 e-y 1 hereby affirm that I am exempt from the Contractor's License MISC.- .' REFER TO ORD INFORMATION u D v, Law for the following reason.(Sec.7031.5,Business and Professions VALUATION $/FT. - PERMIT ISSUANCE 10.00 � mr Code: e,demolish, county which structure, rioo its issuance, also - Q � � ao improve, or repair any structure,prior to its issuance,also ELEC.CONTE.' LIC.NO. - E.TA a G requites the applicant for such permit to file a signed statement that TOTAL 3D �� , PERMIT TO u w m he is licensed pursuant to the provisions of the Contractor's License HzaLaw(Chapter 9(commencing with Section 7000)ofDivision 3 of the 4 O Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE �0 Ie r o m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES . TYPE CONST . a 3 byany applicant fora permit subjects the my employees ant too civil penally ALTER-DRAIN&VENT-WATER (EA.) 5.00 / of not more than five hundred dollars( � - ❑ n as owner of the property,or(S my employees with wages as BACK FLOW PROTECT.DEVICE. 4.00 RES.UNITS •OCC.GROUP their sole compensation,will the work,and the structure is not intended'or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 5,00 Code:The Contractor's License Law does not apply m an owner of property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00�y S0.FT.FLOOR AREA TOTAL ACREAGE re himself through his own employees,provided that such improve- - or not sold or within ed one or yea, If,however,the building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00 ' or improvement is sold within one year of completion,0m owner- prove r will have the burden of proving that he did not build or im GAS-EA.SYSTEM-OVER 4 (EA.) 2,00 BUILDING USE prove for ,wpose of sale.). r INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB . Otho, - O^I;nss oner of the property,am exclusively contracting with E ❑ ❑ ❑ ❑ . licensed contractors to construct the project(See. 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(EA.) 1.00 - contracts for Such projects with a wnttaclons)licensed pursuant to the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO. ❑ 1 am exempt under Sec. ,BAP.C.fyr this WATER HEATER W/VENT 6.00 reason Owner Date WATER SYSTEM 5.00 ACC.DATE - ACC.FILE NO. WORKERS'COMPIENSATION DECLARATION WATER,TREATING EQUIP. 5.00 I hereby affirm that I have a certificate of consent to self-insure, or'a certificate of Workers'Compensation Insurance,or"a certified ZONING ENG.SITE NO. copy thereof(Sec.3800,Lab.C.). - Policy No. Company - O O Certified ropy is hereby furnished. RE SPRINK ENERGY T" Z Z ❑ Cerb6�d.,egpy 'a f d wit 0 ej nspection division. - 24 H O Applicant ` VN i �<� -�-- MISC.- REFER TO ORD. ' v N v N CC CFRTIFICATE OF EXEMPTION FROM WORK F RS' PERMIT ISSUANCE, 10.00 U � FLOOD ZONE A.L.U.C. L COMPENSATION INSURANCE. PLG.CONTE. LIC.NO. PLG - Q- O (This section need not be completed if it,, permit is for one TOTAL a Y N Y C N 0 Z hundred dollars(S 100)or less.) U O I certify that in the performance of the work for which this per- p.T,, MECHANICAL PERMIT FEE FEE SUMMARY LL H mit is issued,I shall not employ any person in any manner so as In O become subject to the Workers'Compensation Laws of California. �x y Date Applicant t ALTER OR ADD TO MECH. 5.00 BUILDING //O S E1 } ro NOTICE TO APPLICANT If,after making this Certificate Of Ex- FZ coalition,you should become subject to the Workers'Compensation APPLIANCE - 5.00 PLAN CHECK provisions of the Labor Code, you must forthwifh_comply with O FEE U such provisions or(his permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 4.00 CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 100DCEM.)-6.00 ' SEISMIC FEE OS^ I hereby affirm that the wore 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,nder's .am - HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC 36 I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) '4.00 information n correct I agree to comply with all city and county PLUMBING ordinances and state laws relating to is building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 above-ereby above-mentioned representatives ec this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL above-mentioned property for inspection purposes. � (We)-agree to save, indemnify and keep,harmless the City of MISC.- .REFER TO ORD. - M upertino against liabilities,judgments, costs and expenses which CONST.TAX' ay in any way accrue against said City in consequence of the ' ' 'PERMIT ISSUANCE 10.00 O matin Of this permit. �e�� MECH.CONT. LIC.NO, MECH. �• TOTAL a.s TOTAL �'7s Signa are of Applicamo-m tractor TIRE / i `, OFFICE COPY .