4664 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING tr APPLICATION 4664
ADDRESS
�7 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
O E PLAN CHECK VALIDATION
\/ NAME QTY. ELECTRIC PERMIT FEE
S ver PHONE
NAUE CONTRACTORS 200 OUTLETS-SWITCHES-RECEP 5.00/1.00
NAME
Cu ertino Electric Lac.NO. 174637 30 LIGHTING FIXTURES 5.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS
712 E. Evelyn Avenue4ONE 245-1000 2 PANELS 5.00 In o DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
PERMIT VALIDATION
'
ARCH.OR Ervc SPECIAL CIRCUIT 5.00
ADOREss 712 E. Evelyn Ave.
Sinn vale Ca. 94086 ZIP EMP.METER OR POLE INS. 15.00
APPLICANTS MOTORSSEE FEE SCH.
ADDRESS It 11 /��/(Y�}
SERVICE CHANGE 10.00 � ` J
'02 LICENSED CONTRACTORS DECLARATION
u 1 hereby uff'inn that I am licensed under prrvisions of Chapter 9HP
ISSUANCE DATE
yah (commencing with Section 7000)of Division 3 of the Business and BLDG ELECT. PLG. MECH.
r- y z Professions Code,a d 1�y license is in full force and effect. ❑
z o�C / Lic CI -LO-Lie Numb•r_1-7-463'7---- ❑ ❑
o ,r HX Date-�8 Cnntraetn upe=tl-node p
`a x f _a NOV 2 9 19Q BUILDING PERMIT
Ir w ¢ OWNER-BUILDFR DECLARATION INFORMATION
x 3 A, 1 herebyfirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
a p VALUATION $/FT.
_ a. o J Law for the following reason.(See.7031.5.Business and Professions PERMIT ISSUANCECit .00
Code:Any city or county which re Alio s e hermit to conSUoaL alter,
6 ¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO, 7 37 ELEC.
O Ix rcyuires the applicant for such permit to file a signed sratlmem that TOTAL 27.5o PERMIT TO
whe is licensed pursuant to the provisions of the Contractor's License LC7
w Law(Chapter 9(commencing with Seaton 7000)of Division 3 of the C•
i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ the basis for the alleged exemption.Any violation of Section 7031.5 1 STORIES TYPE CONSTR.
s. by any applicant for a Permit suhjects the applicmv ma civil penalty ALTER-DRAIN -WATER IEA.) 4.00
of not more than five hundred dollars 6500).1:
❑ [,'as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 ODD.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Protessions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 50,FT,FLOOR AREA TOTAL ACREAGE
. ructasfre utintede ownffered acs,pr.If,however.the
improv'- GAS-EA.SYSTEM-1 4.00
hems are not intended.,offered fend for sale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden oI'proving that Ito did not build or int- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ [,as owner of the property,am exclusively contracting with El El ❑ 13 El
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Prrfcssions Core:'I'lie 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 contrxctorlsl licensed Pursuant to
the Cnntm'mr'a Lice use Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT No. PARCEL NO.
❑ lamexemptunder Sea .B,&P.Cfor Ihia WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DELLA RATION WATER TREATING EQUIP. 4.00
I hereby affirm that 1 have a certificate ol'c.nsenl to xll=insve. ZONING ENG.SITE NO.
or a certificate of Workers'Crmpensalion Insurance,or a certified
copy thereof(See.3800,LAC.).
Policy No. Compamy
O ❑ Certified copy is hereby famished. FIRE SPRINK ENERGY T 24
Z Z ly Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N
H
O nnPm:mti
t-Cuperno-E-leetric-I-nc-
ern CERTIPICATI:OF I'XFMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLODDzorvE A.L.U.C.uc
Ill > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
0- D (This section need not he completed if tire r e Permit is for line TOTAL v El N v F] IN
0 Z hundred dollars IS 100).11111.)
U Q 1 certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I Shall not employ i mY person in:my nwnnerw as to
00become subject to the Workers'Compensation Laws of California. BUILDING
GO Date Applicant ALTER OR ADD TO MECH. 4.00
} tan NOTICI7 TO APPLICANT: IL after making this Certificate of Ex-
F Z coalition,you slmuld become subject In the Workers Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. HEATING UNIT (TO 100,000 B.T.U.) 4.00 MICROFILM
J097,Civ.C.l.
Lender's Name HEATI NG UN IT'OV
100,000 B.T.U.0.50 ELECTRIC ..Z 7`�
Lender's Address
1 certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is cornet. I agree to comply with all city and county PLUMBING
ordinances and store lows relating to building construction, anti BOILER-COMPI3 H.P.or 100,000 B.T.U.1 4.00
hereby authoriec representatives of this city' to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
ubovomennoned property'for inspection put .a.
(We) agree to save, indemnify and keep armless the City.I MISC.- REFER TO ORD.
C tino against liabilities,judgments, co and expenses wheel PERMIT ISSUANCE 3.00 CONST.TAX
ay in any ay accrue again saiA p consequence o h
Starting of mit. / _ M H.CONT. LIC.NO. MECH.
TOTAL TOTAL
- Sil,n' rc A moot( on ,Ictor Datc
OFFICE COPY