18659 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY
BU LDI NO PROJECT IDENTIFICATION PERMIT NUMBER
aNaDING APPLICATION & PERMIT 1
ADDRESS 8 OO J JJ
I okcJ r- - BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 8 + 5(,
OWNER'S
NAME Ri �h DTV- ELECTRIC PERMIT FEE L N ECK VALIDATION
e PHONE I
CONTRA T 'S p�
N�MjE _ P UTLETS-SWITCHES-RECEP 10.00/1.00 'v 19 1992
Mrd i I one d AI
Llc.No LIGHTING FIXTURES 10,00/1.00
CONTRACTOR'S _✓- - a /v
PPLIANCES-RESIDENTIAL 4.00
1 11R^Ess 0hQf,( tf. PHONE l PANELS 10.00 DATE OF-APPLICATION
ARCHITECT PLAN CHECK FEE
PANELS (OVER 200 AMP) 20.00
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH,OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.
ZIP EMP. METER OR POLE INS. 20.00
ADDRESS
AMOTORS SEE FEE SCH.
ss
SERVICE CHANGE 20.00
wo o LICENSED CONTRACTORS DECLARATION I A I {/
a i u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
HA ¢ O1 (commencing with Section 7000)of Division 3 of the Business unit SLOG. ELECT. PLG. MECH.
r O i Professions Code an license is in lull fo an If cI t ❑ ❑ ❑
o i o Licenx las Lic.NuntH f
J Date
Contractor,
1 IM : Y I
a y f D � �2 A BUILDING PERMIT
¢ 0 OWNER-BUILDER DECLARATION INFORMATION
E:
g y 1 hereby affirm that I ant exempt front the Contractors License MISC.- O O VALUATION
S/FT.
S. Law for the following reason.(Sec.70715,Businessand Professions PERMIT ISSUANCE 10.00
Ew�4 Code:Any city or county which requires a permit to construct, _
¢ m ¢0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. EL
u w m u requires the applicant for such permit 10 file a signed statement that To PERMIT TO
he Is Ilwse
nd pursuant to the provisions of the Contractor's License
rzi
Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe
4 c Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ r c� the basis For the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n , by any applicant for a pencil subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).1:
❑ I,as owner of the properly,or my employees with wages as BACK F LOW PROTECT.DEVIL 4.00 Dec.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, OND. 5.0
Code:The Contractors license Law does not apply to an owner of
_ property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
imself or through his own employees,provided that such improve-
nemsarenotintendedoroffered oyees,sale.roided that suhebuildingmproe- GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS-EASYSTEM-OVER 4(EA) 200 BUILDING USE
builder will have the burden of proving that he did not build or im . . .
for RES IND CON PB Other
prove 1,aso nee of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am rojectiv Se contracting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to antr owner of property who builds t r improves user] u and who LAWN SPRINKLERS-OVER 6 (EA.) 1.00
contracts for such cense L with n contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date. WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORK ERS'COMPIiNSATION DECLARATION WATER TREATING EQUIP. 5.00
1 herchy affirm that I have a-certificate of consent to self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certificl
copy then@@ggIJJ$$y c,�B8jjQ Ip.ny.),/1,,��Y
Policy Noil&Y, (I0,L.ny • )Or 1�f��.
0 ❑ Certified copy is hereby funsishL FIRESPRINK ENERGY T 24
Z 2 Cerlifyy..•�Q�c��o��yyrZ is Gled wity sey ty inspection division.
O Anglicant_L.n�1Gf.I=h.�3CQ- Y Misc.- REFER TO ORD. Y C:] NC v ❑ NE]
jr- y CIi R'1'IFICATE OI'EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG,
Z (This action need not be completed if the permit is lin one TOTA V N� Y ry�
hundred dollars(S 100)or le..)
0 O 1 certify that in the performana of the work for which this per- OTV MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner so as In
become subject to the Workers'Compensation Laws of California.
Date Applicant BUILDING
Ed ALTER OR ADD TO MECH. 5.00
} m NOTICE TO APPLICANT': If,after making this Certificate of Ex-
L,. Z emptian,you should become subject to the Workers'Compensation APPLIANCE - 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith Comply Will)
G.1 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4, -
FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10000QflM.) 6.00 SEISMIC FEE
I 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(Sec. MICROFILM
3097,Cie.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.0
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 `
Lender's Address ELECTRIC
I certify first I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
nation is correct. I agree to comply with all city and county BOILER H.P.Or 100,000 B.T.U.) 6.00 PLUMBING
ne '.�
aes and state laws relating to building construction, and
y enthorim representatives ec This city t0 enter upon the
au
bove-mthored property For inspection purpurposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH MECHANICAL T�
a
(We) agree to save, indemnify and keep hmmless the City of misc.- REFER TO OR
upertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
ranting of this permit MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Slgnatureof ApplicantjConlmctor Date
OFFICE COPY