18471 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT q p A q�
ADDRESS 21848 Corte Madera BUILDING -ELECTRICAL-PLUMBING-MECHANICAL i4 184 I
OWNER'S PLAN CHECK VALIDATION
NAMEELECTRIC PERMIT FEE
• Paul French 257-769
DTY,
VNONE
CONTRACTORSUTLETS-SWITCHES-RECEP 10.0011.00
NAME Q
.A.A. Furnace LIC.NO, 0850 3 LIGHTINGFIXTURES 10.00/1.00
CONTRACTORS PPLIANCES•RESIDENTIAL 4.00
/1L Stone Ave. PHONE 293-47 PANELS 10,00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
PERMIT VALIDATION
ADDRESS END' SPECIA CIRCUI 5.00
ADDRESS
ZIP TEMP.METER 0 POLE INS. 20.00
APPLICANT'SOTOS$ SEE FEE SCH.
ADDRESS
1711 Stone Ave . San TRAP
VIC A G 20.00
o 02 LICENSED CONTRACTORS DECLARATION
M W vI hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w<N (commencing with Section 7000)of Division 3 of 1 usiness and BLDG. ELECT. PLG. MECH.
R N i Professions Cote.,qfj ottiezP1e is in full force3nd 4 1
z o m - License Class xl.ic.NumberlContract
0 ❑ ❑ ❑
9Z w Date-3-2-0-94-12 ontractor
a Y w BUILDINGPERMIT
w u OWNER-BUILDER DECLA . INFORMATION
Z
;u R 1 hereby affirm that I am exempt from t 's t MISC.- REFER TO ORD
oa Law for the following reason.(Sec.7031.5, dP 'ons PERMIT $ WCf 10.00VALUATION E/FT.
- Code:Any city or county which requiresapstr I.alter.
m 7 f nee,also ELEC CONT I IG NO. ELEL.Q o improve,demolish,or repair any tructure,- O u requires the applicant for such permit to filmens that TOTAL PERMIT TO
w$w he is licensed pursuant to the provisions of the Contractor's License
ce x r Law(Chapter 9(commencing with Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and O PLUMBING PERMIT FEE
E$ the basis for the alleged exemption.Any violation of Section 7031.5 It I I
DRIES TYPE CONSTR.
i; _ by any applicant for a permit subjects the applicant toacivil penalty ER-D IN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as ACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.uN1T5
their sole compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions ORAINS-FLOOR,ROOF,AREA,CONO. 5.00
Code:The Conlmctor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work OIXTUR ES•PER TRAP 5.00 SQ FT.FLOOR AREA TGTAL ACREAGE
himself or through his own employees,provided that such improve-
4 mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-111NC.40UTLETS 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 im- RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE IN ER. 30.00
❑ I,as owner of the property.am exclusively contracting with ❑ Cl C] 1:10
licensed contractors to construct the project(Sec. 7044.Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORSPAR GELNO.
and Professions Code:The Contractor i License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contracions)licensed pursuant to
the Contractor's License law. SEWER-SANITARY-STORM EA.200tt/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. .B.&PEC.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ALC.DATE ALC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a Certificate of earn nt to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy IhCoca (Sec.3800.Lab.C.).
Policy No. pany
❑ Cert 'opy,s ereby fu i FIRE SPRINK ENERGY T-24
Z Z ❑� Ce (red opy is file ith the C inspection division. MISC.- REFER TO ORD.
0 AprlicanI Y ❑ N❑ V❑ N❑,
F- H PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.L.
CE IFICATE OF MPTION FROM WORKERS'
UJ0 COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLO, V❑ N❑ Y❑ N❑
(This section need not be Completed if the permit is for one TOTAL
Z hundred dollars IS100)or less.)
U 0 I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
u. tmit is issued,I shall not employ any person in any manner so as to
U become subject to the Workeri Compensation Laws of California. BUILDING
0 a
Date-Applicant ALTER OR ADD TO MECH. 5.00
} H NOTICE TO APPLICANT: IL after making this Certificate of Ex.
F 2 emption,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
5..1 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=12-F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued ISec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct.I agree to comply with all city and county BOILER-COMP13 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this City la enter upon Ilse g01LER•COMP IoYer 100,000 BTU)SEE FEE SCH. MECHANICALal
above-mentioned properly for inspection purposes.
(We) agree IO save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
upertino against liabilities,judgments, costs and expenses whichCONST.TAX
way accrue against mid City in consequence of the PERMIT ISSUANCE 10.00
anlipg of his permit MECH.LONT. LIC.NO, MECH.
20-90 TOTAL_ J D TOTAL
tlC
Si re of Applicunon clot Date f.�J
OFFICE COPY