14582 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN-ONLY
BUILDING PROJECT IDENTIFICATIONPERMIT NUMBER'
601LDING' ' APPLICATION & PERMIT
ADORES �1 145,62
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL �
VOvINER'S 7 J J 1' - PLAN CHECK VALIDATION'
"nme 1 QTY. ELECTRIC PERMIT FEE -
lJEC 3 S/
PHONE
CONTRACTOR
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
uc.No. - LIGHTING FIXTURES 10.00/1.00 _
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00
ADDRESS _
11 PHONE PANELS 10.00 DATE OF APPLICATION
, ARCHITECT PANELS (QUER 200 AMP) 20.00 PLAN CHECK FEE ,P.ON .
• OR "
ENGINEER '•
LIC,No, SIGNS TRANS. 3.00
ARCH.OR ENG, SPECIALCIRCUIT 5.09 PERMIT VALIDATION
ADDRESS "
zu, EMP.METER OR POLE INS. 20.00 T
As MOTORS SEE FEE SCH.
AODR DOR ESS ESSr
SERVICE CHANGE 20.00
0 0 0 LICENSED CONTRACTORS DECLARATION (/ • '
¢ra I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE GATE
¢ z w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT, PLO. MECH,
wi Professions Code,and my license is in full force and effect. ,0
o i
!-n W License Class Lie.Number
Date Contractor
a ,to 2 BUILDING PERMIT
¢ ¢ w ¢ OWNER-BUILDER DECLARATION INFORMATION
K 0 a ° MISC, REFER TO ORD '
w g e- I-. .1 hereby affirm that I am exempt from the Contractor's
License
ac LL Law for the following reason. 7031.5,Businessand Professions ,PERMIT ISSUANCE '10.00 VALUATION $/FT.,
Code:Any city or county which requires a permit to construct,alter,
¢ 2 ¢ 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- o u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
_ 6 w he is licensed pursuant to the provisions of the Contractor's License
rZi
FEE
Law(Chapter9(commencingwith Section 7000)o1Divislon 3 of Ore
¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT
Kfo the basis(..the alleged exemption.Any violation ofSection 703 L5 STORIESTYPE CON6TR,
by any applicant for a permit subjects Ore applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
-
of not more than five hundred dollars(5500).)',
-❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT, DEVICE 4.00 OCC.GROUP RES.UNITS
their sale compensation,will do Ire work,and the structure is not
intended or offered for .It (Sec. 7044, Business and Professions DRAINS-FLOOR;ROOF,AREA,COND. 5.00
Code:The Contractor's 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 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve
1 ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00 '
or improvement is sold within one year of completion,the owner- , GAS-EASYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or ma- . RES IND CON -PS Omar
prove for purpose of solo.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of the properly,am exclusively 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 an owner,of proPcrly'whR builds or improves thereon,and who LAWN SPRIN KLERS-OVER 5(EA.) 1.00
contracts for such projects with a 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
mason'
JO Owner .Date - WATER SYSTEM 5:00 _
ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION. WATER TREATING EQUIP. 5.00 -
hereby affirm that I have u certificate bf consent filter resume, ZONING
or a certificate of Workers'Compensation n Insurance,or a certified, ENG.SITE N0.
copy thereof(Sec.3800,Loh.C.).
Policy No. Company ,
Q, ❑ Certified copy is hereby furnished. .FIRE SHRINK ENERGY T-24
Z Z ❑ Certified copy is fled with the city inspection division. MISC.- REFER TO ORD.
O Applicant - - " - Y ❑ PIE] V ❑ N❑
wPERMIT ISSUANCE 10.00
� - - CERTIFICATE EXEMPTION FROM WORKERS; PERMIT ZONE A.L.UF.
W > COMPEE NSATION INSURANCE : PLG.CONTR. LIC.No. PLG.
EL Z: =(This section need nut be completed if the Penn it is for one TOTAL Y❑ NE] Y❑ ❑
IN
hundred`dollars IS 100)Or less.)
U O I certify that if the performance of the work for which thisTeq QTY MECHANICAL PERMIT nab FEE FEE SUMMARY
LL H mit is Isxled,I shall not employ any peam,up any manner so as to _ 7
() become subject(.the Workers Compensation Laws of Culimmia. Nw BUILDING
Ed Date • Applicant ALTER OR ADD TO '
} N NOTICE '1'O APPLICANT: If,after making this Certificate of E. 5'
?' enhption,you should become subject to the Workers'Compensation APPLIANCE 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 .F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 -SEISMICFEE
I hereby affirm that there is a construction lending agency for. EXHAUST HOOD(WITH DUCT) 5.00
the'purformance of the work fo.•which this permit h iswed(Sec. ,MICROFILM
3097,Civ.C.). - HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's NameHEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that l have read this application.,,it state that the above VENTILATION FAN (SINGLE) 4.00
Information is Forced I agree to comply with all city and county
- PLUMBING
( ordinances and'state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
10 hereby authorize representatives of this city to enter upon the BOILER-COMP'IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
- (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
I may in any way,accrue against said City in consequence of the PERMIT ISSUANCE ' 10.00 Q - '
• �(v
ra,n/tJing of this permit. MECH.CONT. LIC.NO.
l ' J .1J OC � � TOTAL �0 TOTAL
Sign urc�of�canl/Contratm t� DatA
OFFICE COPY