18669 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDING PROJECT 1 DENTI'FICATI ONPERMIT NUMBER
RUILDINc LOT APPLICATION & PERMIT
ADDRESS 18669
IO 3 SGS 1 �Lv� ' BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S ^ PLAN CHECK VALIDATION
'jpwli sl S IG QTV. ELECTRIC PERMIT FEE
^re_12IILY r3,fz6WN PHONE
CONTRACTOR'S
NAME �s UTLETS-SWITCHES-RECEP 10.00/1.00 I
. 51511- LIC.N15b79S5' LIGHTING FIXTURES 10.00/1.00 Qd 7oq 30
. CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADDRESS 'qc� '
D0 �0. PHONE256-71, PANELS 10,00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
DR - PANELS (OVER 200 AMP) 20.00
FNGINEER( L 1s-aIL. LIC. lteb¢j SIGNS TRANS. 3:00
N
AR DR.DH ENC.q�(Tq Pl L,-Nl Wky SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
aggREss �f V l/ �• �•/�t
A &ve i,11 � EMP.METER OR POLE INS. 20.00
ICANrs MOTORS SEE FEE SCH. ? 1�
aoD ss
SERVICE CHANGE .20.00 73L-t-7
0 0 o LICENSED CONTRACTORS DECLARATION
a u u I hereby affirm that I am licensed under provisions of Chapter9 , ISSUANCE DATE
-
n
Q-
(commencing with Section 7000)of Division 3 of the Business and - BLOG. ELECT. PLG. MECH.
H m z Professions Co nd my license is in full force ppd eIf
z a s, - Licenss Class Lic.Num yyyy�AA-LL52 f' i
O F Datey ZZ-gContmctJE�^� l
Q y s d C//LLii RJJ
¢ ¢ w a OWNER-BUILDER DL ATION BUILDING PERMIT
r' MISC.- R RD - INFORMATION
E
;LL I hereby affnn that I am exempt from the Comracler's License
Foo4 Lawforthefollowingreason.(Sec.7031.5,Business and Professions PERMIT ISSUAN 0.00 ]„/J' VALUATION S/FT.
Code:Any city or county which requires a permit toconstrucl,alter, / 7�J
p ¢ ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.GDNTH. LIC.N07 ELEC. G/ . b .•.al
¢ requires tPERMIT TO
he applicant for such permit to file a signed statement that TOTAL !6
u w m U. he is licensed pursuant to the previsions of the Contractor's License
r z r Law le,, "it
Professions
re)or Section 7000)ofll ivision3 of the
x a Business and Professionsxempt or that lie is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢ $ the basis for the alleged exemption.ion.Any violation of Section 7031.5malty STORIES TYPE CONSTR.
a ; by any applicant fora permit dollars the($500).):
mucivil penalty ALTER-DRAIN -WATER (EA.).5.00
of not more than five hundred dollen(my employees
❑ Las owner at the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS-
their sole compensation,will do Ilse work,and the structure is not
intended or offered for sale (See. 7044, Business and I'rofessions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 � .
Code: tire Contractor's License Law does not apply In an owner of V144.JJJ���
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTAL ACREAGE
himself Or through his own employees,provided that such improve- '
nsenrs me ,or intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.40UTLETS 6.00 3383 70L�9 E7/••p'x"-
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.I 2.00
builder will have the burden of proving that he did not build or int- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other vi
❑ I,as owner of the property,mm exclusively contracting with
licensed contractors to construct the pm icct(Sec. 7044,BusinessLAWN SPRINKLERS-1 INC 6 V.B. 600 gssesso R9 PARCEL NO.
and Professions Code:The Contractor's License Law does not imply ,
to an owner of property who builds or inhproves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a con Nactods)licensed pursuant to 111
the Contractor's License Law, SEWER-SANITARY-STORM EA,200ft/10.00 TRACT NO. PARCEL NO.
❑ I:un exempt under See. ,B.&P.C.foi lluis WATER HEATER W/VENT 6.00
reason
Owner - Dote WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORK ERS'COMP17NSATION i ECLARAIAON WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,La b.C.)
Policy No. Company_3EFMD_�LT
Q ❑ Certilied copy is hereby umished. - FIRE SPRINK ENERGY T$4
Z Z Cpy is filep with tip city,tnspection division.
� O Applica �__Llet�6... MISC.- REFER TO ORD. YE) Nv [:) N�
CCN C, fI IOADi OF-EXEMPHON FROM WORKERS' PERMIT ISSUANCE 10.00 LUV FLOOD ZONE A.L.uc.
LU > COMPENSATION INSURANC17 PLG.CONTR. LIC.NO. PLG. ((
CL 0 (This section need not be completed if the pen.it is for one TOTAL �O- 1 O Y❑ NC] Y [3 NC]
V 0 hundred dollars IS 100)or less.)
I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued,1 shall not employ any person in any mm�ner sons to C12-2 O O W become subject to the Workers'Compensation Laws of California.
Q. Datc Applicant - ALTER OR ADD TO MECH. 5.00 BUILDING
>_ N NOTICE TO APPLICANT: If,after making this Certificate of Fs-
F ? emption,you should beconhe subject to the Workers'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 deenmd revoked. AIR HANDLING UNIT(TO 10)000C.F.M.) s0
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER 10=C.F.M.) Er06 '-- SEISMIC FEE
I hereby affirnh that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) • 5.00 airy
the performance of tie work for which this permil is issued(Sec. MICROFILM r�
3097,Civ.C). HEATING UNIT ITO 100,000 B.T.U.)' 18.00 _
Lender's Name H EATING UNIT 100,000 B.T, a
LendeKs Address .11DA 1 ELECTRIC
Iccrlily thmlhuvc read lhisapplinJion and state that the ahove ' VENTILATION FAN (SINGLE) '4.00 -
information is correct.I agree to comply with all city and county BOILER-COMP(3 H.P.OT 100,000 B.T.U.) 6.00 PLUMBING b -
ordinances and state laws relating to building construction, and
hereby uutharize representatives for ins inspection
this city to enter upon theabove- BOILER-COMP (Over 100,000 BTUI SEE FEE SCH. MECHANICAL _
henebm entimmomed property forinsp of this
puity ts.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
upertino against liabilities,judgments, costs and expenses which CONST.TAX
'n any way accrue against sai Cit in consequence of tum PERMIT ISSUANCE 10.00 0
ranlin (this peirsp t. _ - Z MECH.CONT. LIC.NO. MECH. -
\-C/� TOTAL q6 i TOTAL
Si re Df Applicant/Contractor D to
OFFICE COPY