18297APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT 1 DENTI FICATI ON
APPLICATION & PERMIT
BUILDING — ELECTRICAL— PLUMBING — MECHANICAL
PERMIT NUMBER
O (]
S<' o �7
BUILDING
ADOREic)(55
OWNER'S
PLAN CHECK VALIDATION
"AME
PHONECONTR
OTY. ELECTRIC PERMIT FEE
��t�eS
NAME. crORsxr���'
NAME, ky—r
Cm/yr+`-+\ sec. No.
UTLETS- SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
ADDRESS
APPLIANCES - RESIDENTIAL 4.00
PANELS 10.08
PHONE
DATE OF APPLICATION
ARCHITECT
OR
ENGINEER se/�
x c. rvo. CC
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
'
SIGNS TRANS. 3.00
ARCH. OR ENc'SPECIALCIRCUIT
AODREss n/A
t -p 2IP NIg':
5.00
PERMIT VALIDATION
�j
EMP. METER OR POLE INS. 20.00
Ar'S
ADDRESS
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
Ge.Q
LICENSED CONTRACTORS DI'CLARATION
e2 362— X F 01—T
1 hereby affirm that I am licensed Lord er.... locus If Chapter 9
ISSUANCE DATE
commenning with Section 7000) of Division 3 of the Business and
I'na1'eims Code, and my license is in full force and effect
License Class Lia Number
Date Contractor
B DG.
ELE T.
PMECH.
LG.
G 199
BUILDING PERMIT
AUG
OWNER -BUILDER DECLARATION
I hereby ul'm Onn that 1 uexctnpt from the Contractor's Licemx
Law for the following reason. (Sec. 7031.5, Business and Professions
Code: Any city or county which requires u 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 Contractor's LicenseC
Law (Chapter 9 (commencing 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 Section 7031.5
ON
INFORMATION
MISC. — f ORD
VALUATION
O D 0
$/FT.
_M�O
o
PERMIT ISSUANCE 10.00- t)0
ELEC. CONTR. LIC. NO.
ELEC. �/,
TOTAL `
yyl r
ou
ORI 3Y C
QTY. PLUMBING PERMIT FEE
by any applicant for a permit subjects the applicant to a civil penalty
of nut mote than five hundred dollars (8500).):
ALTER -DRAIN & VENT -WATER (EA.) 5.00
jwn
❑ 1, as owner of the property, or my employees with wages as
their sole co mpensation, will do the work, and the structure Is not
BACK'FL PRQTFCA. (WIE V 4-90 -1
OCC. GROUP
RES. UNITS
intended ooffered for sale (Sec. 7044, Business and Professions
DRAINS-4Cb& EllI 5. 0
Code: 'Fhe Commetor's License Law does not apply to an owner of
property who builds orimproves thereon, and who does such work
+FIX' URE 'P fl-Tfj'AP
0
So. FT PLepR AREA
TOTAL ACREAGE
himself or through his own employees, provided that such improve-
meats are not intended or offered for sale. If, however, the building
' GAS - EA. YSTEM - 1
`4
Ijej+� (r(vr
or improve nei t is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im-
prove for purpose of sale.).
❑ 1, as owner of the property, um exclusively contracting with
licensed contractors to construct the project ISec. 7044, Business
and Professions Code: The Contractor's License f.aw docs not apply
to an owner of property who builds or improves thereon. and who
- GAS - EA. SV '- OV O
BUILDING USE
RES IND CON PB Omar
❑ ❑ ❑ ❑ ❑
NDUS,T.RIAL WASTE INTER. 0.00
-
WN INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts forsuch projects with a contracloKs) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO,
PARCEL NO.
❑ I am exempt under Sec.—. B &P.C. for this
reason
WATER HEATER W/VENT 6.00
Owner Duce
WATER SYSTEM 5.00
ACC. DATE
ACC, FILE NO.
WORK ERS'COMPENSA'I'ION D&LARA'rION
WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconsent to self -insure,
U, a certiGeatC of Workeri Compensation Ins. r ... C, or a .ertfied
x .�
ZONING
ENG. SITE NO.
copy thereof (See. 3800, Lab.CJ.
Policy No. Compary
FIRE SPRINK
ENERGY T-24
❑ Certified copy is hereby furnished
❑ Certified copy is fled with the city inspection division.
Applicant
Y ❑ N❑
Y ❑ N❑
MISC. - REFER TO ORD.
CERTIFICA11; OF EXEMPT ION PROM WORKERS'
PERMIT ISSUANCE 10.00 _(�
FLOOD ZONE
A.L.U.C.
PLG. CONTR. LIC. NO.
PLG. y •D ,\
TOTAL /
COMP17N'SA'I' ION INSURANCE
1'fhis section need not be completes] if the permit is for one
Y ❑ N ❑
Y ❑ N❑
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars IS 100) or less.)
1 certify that in the performance of the work For which this per-
mit is issued. I shall not employ any person in any manner so as to
become subject m the Workers' Compensation Laws of California.
Dare Applicant
NOT ICE 'T'0 APPLICANT: it, otic, hulking this Certificate of Fs-
Cmption, You should become subject to the Worker' Compensation
BUILDING'
GD
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
provisions of the Labor Code, you must litrthwith comply with
such provisions or this permit shall be deemed revoked.
FEE--
AIR HANDLING UNIT (TO 10,000C.F.M.) 4.00
AIRHANDLING UNIT(OVER 10=C.F.M.) 6.00
SEISMIC FEE
or
CONSTRUC'T'ION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
I hereby affirm that there is a construction lending agency for
., which this pert is issued (Sec.
he ped.,.. aoce of the work Imi
t .
3097, Civ.C.).
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER 100,000 B.T.U.) 9.50
ELECTRIC
_
I.endC,'s Name
Lender's Address—
VENTILATION FAN (SINGLE) 4.00
PLUMBING
I certify that I have read this application and state that the above
Information is correct. 1 agree to comply with all city and countyBOILER-COMP(3
ordinances and state laws relating to building construction, and
H.P-or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,Oo0BTU) SEE FEESCH.
MECHANICAL
hereby .uthoriee representatives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
CONST. TAX
(We) agree to save, indemnify and keep harmless the City of
uperlino against liabilities, judgments, costs and expenses which
may in any way accrue against said City in consequence of the
PERMIT ISSUANCE 10.00 ,t.1
MECH. CONT. LIC. NO. MECH.
TOTAL -7(-Cr
TOTAL
q
ranting of This permit '
Signature of Applicant/Contractor Date
OFFICE COPY