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2906'%PPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT BUILDING - ELECTRICAL- PLUMBING - MECHANICAL PE IT E Q O `J PLAN CHELK VALIDATION ' DATE OF APPLICATION BU mtmrc ADGRESs 10,2_1T- OYNER'S "AME��.x� �� �'�7{� PHONE 77-7- / 7/Z/ _ a.Ln .4Y O „ -ELECTRIC PERMIT , ^"FEE. �cONTRAcionsUTLETS-SWITCHES•RECEP AMEAlIt. J F -1 -JE I Z'( -LIG. NO.2-5LC Z 5.00/1.00 J IGHTING FIXTURES 5.00/1.00 CONTRACTOR'S RELC <n ��A/ rl4T -IJ APPLIANCESADDRESS-RESIDENTIAL 4.00 PANELS 5.00 ARCHITECT OIL OR ENGINEER LIC. NO. SIGNS 6.00 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 ADo 'ESS E"O' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION EMP. METER OR POLE INS. 15.00 ZIP / APPLICANT'S ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 10.00 LICENSED CONTRACTORS DECLARATION PISSUANCE I hereby affirm that I am licensed under provisions of Chapler 9 DATE (commencing with Section 7000) of Division 3 of the Business and Professions Code rdfiblicenu is in full fore eff - Licen�[)ass Lic. Number -Z Date 1.�LL- I Contractor BLDG. ELECT. PLG. I MECH. ❑ ❑ ❑ DEC 14 198 yl;'�s'�'";,'kBUIL'DING PERMIT' S�V*; T"';IINF.ORMATIONFj??{j'a OWNER -BUILDER DECLARATION"s,; I hereby affirm that 1 am exempt from theContractor's License p Law forthe fo0owingreason.(Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter. improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractors License Law (Cha ter 9(commencin with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Sect ion 7031 5 MISC. - EFER TO ORD PERMIT ISSUANCE 6.00 VALUATION $/FT.. ELEC. CONTR. LIC. NO. ELEC. TOTAL PERMIT TO EL�.Z7 °� "'A `t'- / +Yid y''%' QTY. , -'p 1. -PLUMBING PERMIT FEE v; .3:� -'a ^sr: u. �.4., .m .. 2ea!r LYi aL'G ; STORIES TYPE CONSTR. by any applicant for a permit subjects the applicant too Civil penalty of not more than five hundred dollars (SS00).): ALTER -DRAIN & VENT -WATER (EA.) 4.00 ,2I, as owner of the property, or my employees with wages as Their sole compensation, will do the work, and the structure n not BACK FLOW PROTECT. DEVICE 2,00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, COND. 4.00 intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who dues such work himself or through his own employees, provided that such improve- menta arc not intended or offered for sale. IL however, the building FIXTURES - PER TRAP 4.00 SO. FT. FLOOR AREA TOTAL ACREAGE GAS-EA.SVSTEM-iINC.40UTLETS 4.00 or improvement is sold within one year of completion, the owner- wilder will have the burden of proving that he did not build or im- ave for purpose of sale.). ❑ 1, as owner of the property, am exclusively contracting with GAS • EA. SYSTEM. OVER 4 IEA.) 1,00 BUILDING USE RES IND CON Pe Ornar ❑ ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 20 .00 licensed contractors to construct the project (Sec. 7044, Business 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- 1 INC 5 V.B. 5.00 LAWN SPRINKLERS -OVER 5 (EA.) 1.00 ASSESSORS PARCEL NO. contract, for such projects with a eontraclods) licensed pursuant to the Contractor's License Law. SEWER -SANITARY -STORM EA. 200ft/8.00 TRACT NO. PARCEL NO. ❑ 1 am exempt under Sec... BAP.C. for this reason WATER HEATER W/VENT 4.00 Date Owner WATER SYSTEM 4.00 ACC, DATE ACL. FILE NO. WATER TREATING EQUIP. 4.00 WORKERS'COMPENSATION DECLARATION 1 hereby affirm that 1 have a certificate of consent to self -insure. or a certificate of Workers' Compensation Insurance, or. certified ZONING ENG. SITE NO. copy thereof (Sec. 3800, Lab.C.). Policy No. Company b'�b•rs= Fao-La� FIRE SPRINK Y ❑ N❑ ENERGY T-24 Y ❑ N❑ ❑ Certified copy is herby furnished. ❑ Certified,Qa H 'Is Jded � t city inspection division. Applicant [ i MISC. - REFER TO ORD. CERTIFICATE. OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD 20hl A. L.U.C. PLG. CONTR. LIC. NO. PLG. TOTAL COMPENSATION INSURANCE (This section need not be completed if the permit is for one v ❑ N ❑ Y ❑ N❑ - - •. t I: fE M i� fs• �"� - � QTY + MECHANICAL PERMIT FEE''. _ j, .,, _-,,,_/, n, Ss,i, - .z,-,: `.i:. a{? I: "-�'� n "'til •1�A'.`.•:4;5 - . s + �'Y'jFEE SUMMARYi J �W 'p ti .s., a Aa hundred doll.. IS 100) or less.) I certify that in the performance of the work for which this per mit is issued, I shall not employ any person in any manner SC as t0 become subject to the Workers Compensation Laws of California. Date Applicant BUILDING ALTER OR ADD TO MECH. 4.00 NOTICE TO APPLICANT: If, after making this Certificate of Ex- emption, you should become subject to the Workers Compensation APPLIANCE 4.00 PLAN CHECK provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked, AIR HANDLING UNIT (TO 10.0MC.F.M.) 3.00 FEE AIR HANDLING UNIT(OVER 10=11F.M.) 5.00 SEISMIC FEE 60v CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00 the 3097 eC',.C.). e of the work for which this permit is issued (See. MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 4.00 Lender's NO. Lender's Address HEATING UNIT (OV ER 100,000 B.T.U.) ELECTRIC I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00 information is correct. 1 agree to comply with all city and county ordinances and state laws relating to building construction, and PLUMBING BOILER- COMP (3 H.P. or 100,000 B.T.U.) 4.00 BOILER -COMP love, 100,000 BTU) SEE FEE SCH. MECHANICAL hereby authorize representatives of this city to enter-upon'the - bove-mentioned property for inspection purposes, MISC. • REFER TO ORD. (We) agree to save, indemnify and keep harmless the City of upertino against liabilities, judgments, cost, and expenses which may in any way accrue against said City in consequence of ther CONST. TAX ERMIT ISSUANCE 3.00 gmnN�Oj'�I this pCr L Lih v �[ . !t'C4.� fist /S YL ONT. LIC. NO. MECH. TOTAL •, i :I - iTOTAL��' - SignatureofApplicant/Contmcmr Date OFFICE COPY