18917 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION ' PERMIT NUMBER
BU,LOING - APPLICATION & PERMIT r p n q
ADDRESS 17
0 J I
W l C BUILDING-ELECTRICAL-PLUMBING,-MECHANICAL
OWNER'S L� PLAN CHECK VALIDATION
NAME •
OTY. ELECTRIC PERMIT FEE 1
G I S u�DO PHONE �I �r L
CONTRACTOR'S
NAME I ( OUTLETS-SWITCHES-RECEP 10.00/1.00
G. �, LIC.No. 'Z LIGHTING FIXTURES 10.00/1.00
TRAC
CDNTa R's
O
HESSCONTRACTOR'S
PPLIANCES-RESIDENTIAL 4.00'
PHONE PANELS 10.00 DATE OF APPLICATION +
OR
RCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEEflLIC. J f_7v U
c.No. SIGNS TRANS: 3.00 /
ADDRESS ARCH.OR ENG, I SPECIAL CIRCUIT 5,00 S'O PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
AMOTORS SEE FEE SCH.
ADDDRESSDRESS
SERVICE CHANGE '20.00 T
wo o LICENSED CONTRACTORS DECLARATION
ce v 1- 1 herebyaffirm that I am licensed under rovisions m'Chi ter9
N¢ Iu p p n, ISSUANCE DATE
< a (conunenc,ng with Section 7000)of Division 3 of the Business and BLDG. ELECT, PLG. MECH.
H y i Professions Code,and my license is in full force and effect.
pZ m W License Class Lia Number
F y H J DateContractor �xr ,y F�
a w¢
OWNER-BUILDER DECLARATION City CUIIBI IIIII� BUILDING PERMIT
A.
;a y 1 hereby affirm that I am exempt frons Ole Contractor's Llcen
§C. REFER TO ORD INFORMATION
w u o J Law for Ilse following reason.(Sec.7031.5,Businessand Prof 'ons PER SUANCE 10.00 VALUATION $/FT.
Code'.Any city or county which requires a permit to construct,a er, fl �TTD
BE
0 improve,demolish,or repair any structure,prior to s historic s C.CONT LIC.NO. SLED.
0¢ requires the applicant for such permit to file a sign I 'tutement I TOTAL a„6 aO MIT TO
a X m a be is licensed pursuant to the provisions of the Con D clots Lie L e PER
Fit Law(Chapter 9(commencing with Section 7000)of Nlsion3 X7(' 3�
E 4 o Business and Professions Code)or that he is exemp lheref I d Q PLUMBING PERMIT FEE I e��1'
r m the basis For the alleged exemption.Any violat inn of 'clio .5 STORIES TYPE CONSTR.
A. ; _ by any applicant for a permit subjects the applicant to civi malty
of on more Chun five hundred dollars 13500)-); ALTER-*II AV ENT-WATER (EA.) 5.00
❑ I,as owner of the property,OF my employees w ages as B K O ECT.DEVICE 4.00 OCC.GROUP REB.UNITS
their sole compensation,will do the work,and the stn 1 re is not
intended nr offered for sale (Sea 7044, IL xincxx an rofessims' DR I R,ROOF,AREA,COND. 5.00
Code:The Contractors License Law dues not n..Per.1
properly who builds or improves thereon,unit who does such work IX - ER TRAP 5.00 SO,FT.PLOOR�.REA TOTAL ACREAGE
himself or through his own employees,provided that such improve- �e
mentsare not intended Proffered forsale.IL however,the building G S A.SYSTEM-11NC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner- G S-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or ran- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB On.,
❑ 1,as owner of the property,anexclusively contracting with - ❑ _1:1 ID ❑
licensed contractors to construct the project(Sea 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 an owner of property who builds or improves thereon,dnd who iLAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts 1'or Such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200tt/10.00 TRACT NO. PARCEL NO.
❑ Iantexemplumer Sec. ,B.&P,C.for this Ii W/VENT 6.00 .
reason__
Owner . Date(- WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSA I ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or u certified ZONINO ENG,SITE NO.
copy thereof(See.3800,Lab.C.). - -
Policy No. Company -
0 ❑ Cerliftedeopyis'herebyfurnished FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division.
F O Applicant t MISC.- REFER TO ORD. - Y E] N Y El NEI
C y CERTIFICATE OF FXEMP'fION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE - A.L.U.C.
W COMPENSATION INSURANCE PLG.CONTR.• LIC.N0, PLG:
CL Z (This section need not be completed if the permit is for one TOTAL YE]
O N_ Y[:] N[:]
U O hundred dollars(S 100)or less.)
I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL f alit is issued,I shall not employ any person in any matter so as to
O W become subject to the Workers'Compensation Law,of California. �-
n Date_ Applicant BUILDING O
} W NO'T'ICE '1 O APPLICANT': If,after making this Certificate of six- ALTER OR ADD TO MECH. 5.00
? emption,you should heroine subject to the WorkerF Compensation APPLIANCE - 5.00 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.) 4.00
CONSTRUCTION LENDING AGENCY - AIR HANDLING UNIT(OVER 10,000C.F.M.) 6:00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) . 5.00 r
the ,Civ.mmuce work for w i h IhI pennii is Issued ISec. MICROFILM
the corn). � HEATING UNIT(TO 100,000 B.T:U.) 8.00
Lender's NamA ` �' U
Lender's Address - HEATINGUNIT(OVER100,000B.T.U.)9.50 -ELECTRIC .Z. 6. 0)
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct, I agree to comply with all city unit county - PLUMBING
ordinances and site laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000B.T.U.) 6.00
hereby f h purposes: vethorirc representatives othis city to enter upon tile
above-menectioned property for inspection e BOILER-COMP(Or 100,000 BTUPSEE FEE SCH. MECHANICAL
'(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
upertino against liabilities,judgments, costa and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
accrue ay in any way against said City in consequence of the
rayy�gg of this pen MECH.CONT. LIC.NO, MECH,
I4- 199 TOTAL TOTALU 63
Signature of Applicant/Contractor Date /� 1�
OFFICE COPY