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14586 (2)✓% Ar ICANT TO FILL IN INFORMATION WITHIN RED LINES•,= USE BALL POINT PEN ONLY - 4BUI LDING PROJECT I.DENTI F16ATION APPLICATION &PERMIT BUILDING — ELECTRICAL— PLUMBING — MECHANICAL -.PERMIT NUMBER _. ' 1�458�6 BUILDING ADDRESS .Z Al. $ J✓Z4' 81✓, OWNER'S - �C' (y�✓ � C " y/�(EE i,$ 1oS /je/ I J/7Ml= PHONE I QTY. ELECTRIC PERMIT FEE - PLAN CHECK VALIDATION' 'x/ s-� ° c RACTOR NAM ' QIJ FI iM OUTLETS -SW ITCHES ';R SCEP 10.00/1'.00 LIGHTINGFIXTURES '10.00/1.00 - " DATE OF APPLICATION PLAN CHECK FEE, -' P.C: NO. - - CONTRACTOR's ADDRESS 7/ I"*9/N�S X);4 PHONE �] —�L3 ARCHITECT `N OR LL ENGINEER uc. NOLO/%a7 APPLIANCES- RESIDENTIAL " '4:00 PANELS 10.00 PANELS (OVER 200 AMP) 20.00 n SIGNS TRANS. 3.00 ARCH.ORENG. ✓ ADDRESS 1 7,7 Z. YFjQ S',EA�Or7 L'}- ZIP $p ECIAL CI RQU IT 5.00 ,' PERMIT VALIDATION' ' so -• EMP. METER OR POLE INS.- 20.00,. APPLICANTS I9,MOTORS ADDRESS Y1'�9>L w TSL �Y Ndry.Y . SEE FEE SCH. - d SERVICE CHANGE .20.00 LICENSED CONTRACTORS DECLARATION I hereby affirm that am, licensed under provisions of Chapter 9 NCE DATE (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Class Lic. Number - L T. PLG. MECH. El 1-1 Date� 3 ( _Cont me to, ��� OWNER-RUILDER DECLARATI I hereby affirm that I so exempt from the Cross and Pr License Professions Law for the following reumn.(Sec.uires ape itto Code: Any city or county which requirese permit to consuact.alalter, Improve, demolish, of repair any sticture, prim to its issuance, t I.. RMIT UILDINGPEION, INFORMATION, MISC.— REFER TO ORD VALUATION $/FT. PERMIT ISSUANCE ' - --10.00 ELEC. CONTR. LIC. NO. ELED. that nedp u applicant for tiro permit ns file a signed statement that requires ilicensed he is licensed pursuant m the provisions of the Contractor's License Law (Chapter 9(commencing with Section 7000) of Division 3 ofthe Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 ° NOTAL PERMIT TO 110, IMPROVE.' QTY. PLUMBING PERMIT - FEE STORIES TYPE CONSTR.' ENT -WATER 5.00 ALTER -DRAIN ' - by any applicant for a permit subjects the applicant toa'civil penalty ofnot more than fivebundmd dolrs($500).): - " ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sc,. 7044, Business and Professions BACK FLOW PROTECT. DEVICE' 4.00DCC. GROUP RES. UNITS , DRAINS -FLOOR, ROOF, AREA, COND. 5.00 Code: The Contractor's License Law does not apply to an owner Of property who builds or improves.thercon, and who does such work FIXTURES - PER TRAP 5.00 80. FT. FLOOR AREA TOTAL ACREAGE . himself or,through his own employees, provided that such improve- ments are not intended or offered for sale. If, however, the building 'or improvement is sold within one year of completion, the Owner - builder will have the burden of proving that he did nal build or int- prove for,purpose of sale.). - to I as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business ' (EA.) RES IND CON - PB Omer ❑. ❑ El El ❑ INDUSTRIAL WASTE INTER. 30.00 LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 -.'ASSESSORS PARCEL NO. and Professions Code: The Contractor's License Law does not apply to as owner of property who builds or improves thereon, and who LAWNSPRINKLERS -'OVER 5 (EA.) 1.00 contracts for such projects with a contractors) licensed pursuant to tlieContractor's'LicenseLaw. - SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO, PARCEL NO. WATER HEATER W/VENT 6.00 .D I am exempt under Sec.—, B.&P.C. for this reason Owner - Date WATER SYSTEM 5.00' ACC.DATE - ACC. FILE NO. WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 . I hereby affirm that 1 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.) A/V- ,ld Policy Ncu Company' 0 Certified copy is ]torch furnishe. ❑ CertifiErP.bpy is fA€d wi01 a sit inspection dlvlsimt Applicant �1 i� t�_�/yyl 1— �- @ - FIRE SPRINK Y ❑ . N ❑ 'ENERGY T-24 .y ❑ N❑ MISC.. 'I REFER TO.ORU .. �_o CHRTIFICAfE OF EXEMPTION FROM WORKERS' PERMIT ISSUA E '`. x5;10'.00' FLOOD 20NE A. L.U.C. PLC. CO NTR. LIC. NO. - PLG., TOTAL COMPENSATION INSURANCE ('This section. need not be completed if the permit is for one Y ❑ N ❑ Y'❑ N ❑ OTY MECHANICAL PERMIT FEE FEE SUMMARY hundred dollars ($100) or less.) I certify that in the performance of the work for wlueh this per- mil is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California.Date Applicant 1O APPLICANT: II, after making this Certificate of Ex- emption, you should become subject to the Workers' Compensation provisionsof the Labor,Code, you must forthwith comply with such provisions or this permit shall he deemed revoked: CONSTRUCTION LENDING AGENCY ALTER OR ADD.TO MECH. 5.00NOTICE APPLIANCE 5.00 - AIR HANDLING UNIT (TO 10=C.F.M.). 4.00 AIR HANDLING UNIT(OVER IO,OODORM.) 6.00 FFEE '7II EXHAUST HOOD (WITH DUCT) 5.00the hereby affirm that there Is a construction lending agency (or performance of the work for which this permit is issued (Sec. 3097, Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00 UNIT(OV ER 100,000 B.T.U.) 9.50 _ Lender's NameHEATING Lender's Address it that l have read this application and state that the above. VENTILATION FAN (SINGLE) - •-4.00' certify information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction; and PLUMBING . BOILER-COMP(3 H.P. oT,100,000 B.T.U.) 6.00 g01LER-COMP (0,g, 100,000 BTU) SEFr.FEE SCH. .MECHANICAL lidrehy authorize representatives of this city to enter upon the. above-mentioned property for inspection purposes. 'rfWe) agree to save, indemnify and keep harmless the 'CBY of upertino against liabilities, judgments, costs and expenses which ma any wny'aceruc against said City in consequence Of the mn[' g any w IL p _ MISC.= - REFER TO ORD. CONST. TAX - PERMIT ISSUANCE 10.00 .. - - MECH. CONT. LIC. NO. -- - MECH.N"t TOTAL'TOTAL 070 .pi ✓(' Weki e' 2-Z-' Ig -tore of Applicant/Contractor Date OFFICE COPY