17833 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT I•'
ADaREu 17833
��Y�-7 1,51 �"+IP�r BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S �L `^L/AV 1 PLAN CHECK VALIDATION
NAME 1"yrl/��f"`1c"� ry-/T ,,( QTY-
OTY. ELECTRIC PERMIT FEE'
�TI�J .PRONE✓✓- '� '
NAME °RaLfl2� UTLETS-SWITCHES-RECEP 10.00/1.00
-
LIC.NOC LIGHTING FIXTURES 10.00/1.00
. '
TR
.ONAcroA'/ !� pp LIANCES-RESIDENTIAL 4.00
CONTRACTOR
f-
PIIONE _ PANELS 10.00 DATE OF APPLICATION '
ARCHITANET PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMPI 20.00
ENGINEER
uc.No. - SIGNS TRANS. 3.00
ARCH
.On ENG. PERMIT VALIDATION
L . ADDRESS SPECIAL CIRCUIT 6.00
ZIP rrEMP. METER OR POLE INS. 20.00 S � ( 0
ASS MOTORS SEE FEE SCH.
ADDREOREs t ( t
SERVICECHANGE 20.00
,00 LICENSED CONTRACTORS DECLARATION
u U I hereby alines that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
rzi Pmtfessions Codc'and myli lction icense nof Uull fore30`'hffBl'siness andMAI BLDG. ELECT. PLG. ECH.
(coZ i L o License Claw Lic.Number-
0
w Date Contractor
a x City of Cnnorfin0 BUILDING PERMIT
a OWNER-BUILDER DECLARATION
Or 0 w o - - INFORMATION
R
;LL h I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD � - VALUATION S/FT.-
H a o j Law furthe followingrcmen.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00 I
Code:Any city orcounty which requires a permit to construct.alter, q''7 /-�,F�/�_
RR¢ 2O. improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEG I 12 /r tn!!! J
u requires the applicant for such permit to file a signed statement that TOTAL 51 PERMIT TO
R
$m he is licensed pursuant to the provisions of the Contractor's License _
Hi >
Law(Chapter 9(commencing with Stelim,7000)of Division 3 of the
< Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
f i o
M H the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant ler a permit subjects the upplicanl toe civil penalty ALTER-DRAIN IEA.) 5'.00
of not mom than five hundred dollars($500).): V-H
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP . RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND- 5.00 �_Z J
Code:The Contractor's License Law does not apply to an owner of
properly wllo builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 So-FT FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale.If however,the building GAS-EA.SYSTEM-1 INC.4OUTLETS 6.00
r improvement is sold within uric 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 am- RES IND CON PB Other
prove forpR,mNcs owner
the.l. INDUSTRIAL WASTE INTER. 30.00 �/ ❑ ❑ ❑ ❑
❑ d as owner of the property,am exclusively contracting with
licensed romocors to construct the project(Sea 7044,Business LAWN SPRINKLERS-1 INC 5 V.8. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's 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 welt project,will,a rontr etmfsl licensed pursuant to
the Contractor's License Luw. SEWER-SANITARY-STORM EA.20 1 NO. PARCEL No.
❑ lam exempt under Sec._,B.&P.C.for thes WATER HEATER W/VENT '
reason
Owner Date WATER SYSTEMFFLOODZONE
CC.FILE NO.
WORK ERS'COMPENSATION DECLARATION - WATER TREATING EQUIP.
I hereby affirm that I have a certificate of convent to self-insure. NG ITE NO.
or a certificate of Workers'Compenmtion Insurance,or a certified
copy thereof ISZ8OOb.CJ.Policy Arco. b"0 ❑ Certified on
by lumeshed. NERGY T-24
Z Z ❑ Certifieded �th tl city impec ' I division-O A 'cant MISC.- REFER TO ORD. v ❑ N❑~ PERMIT ISSUANCE 10.00A.L.U.C.
A11i 01' !�(I.M IOIV 'RON VURKERS'
LU > COMPENSATION INSURANCE PLG.CONTR. - LIC.NO. PLG. 11,
CL ❑ IT his section need nor he completed if Ole permit.N for one s TOTAL �� v❑ N❑ v ❑ N❑
::) Z huad'ed not.is(5100)or lc.T
U O 1 Unlit,that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued, 1 shall not employ any person in any n armee so as In
O w become subject to the Workers'Compensation Laws of Califom..
d Date-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING T-- co
} res NOTICE TO APPLICANT: If,atter wking this Certificate of Ex-
F ? emption,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN'CHECK'
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000 C.F.M) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE S
I hereby from that them 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,Civ.C.). HEATING UNIT(TO 100,000 B:T.U.) 8.00
Lender's Name H EATING UNIT(OVER 100,000 B.T.U.)9.50 G
Lender's Address ELECTRIC �I
I cerlily that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is soul t.I agree to comply with all city and county PLUMBING �os
rudinunce, and state In.N relating to building cunalmetiam, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 rJ�
hereby authorize representatives of the city to enter upon the BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree�ap;, indemnify and keep harmless the City of MISC.- REFER TO ORD.
upertino agar raabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX �a 7�
icy n any accrtm aainsl cid Cily in curs. Iym` r�(cv o.thC
ranhngo ' pcwnt� 7A/!/�//T/ �//' MECH.CONT. LIC.NO. TOTAL TOTAL
m8 / /0•G`J
I lure o Applicant/Contractor
Dale 5
OFFICE COPY '