14678 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY _
.,BUILDING PROJECT 1
DENTI FI
PERMIT NUMBER
APPLICATION & PAT
BUILDING
ADDROS1N ` PN BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 146
78
kOOFF
OWNERS PLAN CHECK VALIDATION
NAME IIL 415- CITY.CITY
ELECTRIC PERMIT FEE_
G Y"' -C-0 '4p"lA PHON
CONTRACTORSN51 OUTLETS-SWITCHES-RECEP 10.00/1.00
AME Sprig ,$lect);ig . .
ICNo296728 C1 60
� LIGHTING FIXTURES 10.00/1.00
GONTRACTOR s
ADDRESS pPLIANCES-RESIDENTIAL 4.00
1303 Lick Ave. SJ PHDNE298-3134 1 PANELS 10.00 DATE OF APPLICATION'.
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
oR
ENGINEER
uc.NO. SIGNS TRANS. '3.00
ARCH.OR ENG SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS Heat PUM &STRAMgSCH.
ADDRESS
SERVICE CHANGE 20.00
T o LICENSED CONTRACTORS DECLARATION l/ U
G U U I hereby afEr1» that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
vs G i tcommen,ir,with Section 7000)of Division 3 of the Business and BLDG. ELECT. I PLG. MECH.
H m i Professions Code.anALDlI�ense is in full fora"2 `tr'` �n ❑ r-xF ❑ ❑
z o w- License Class_ se i Num��++�� 1� ��" QJ(`
o z H w Dam_6/28/Q$_Contractor,yYrl e.r Q
a Y f `�� )) Oki BUILDING PERMIT
,w a OWNER-BUILDIiR DECLA'A'1'[ON INFORMATION
U REFER TO ORD
E
u H I hereby affirm thin I am exempt Iran the Contmefor's License MI$D.- VALUATION
e1 LL 0 4 Law for the following reason.(Sec.7031.5.Busimnsand Professions PERMIT ISSUANCE .1AI@@
Code:Any city or county which requires a permit to construct,alter,
K<0 improve,demolish,or repair any stnmlure,prior to its issuance,also ELEC.CONTR. LIG.NQ ELEO. r�
O u rquices the applicant for such pennil m lilt a signed slulement(hat TOTAL ��V PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's License S Yl Ele /'
Lf-_
F z a
Law(Chapter 9 fcomlmencing with Section 7000)of Division 3 ofthe C ��
Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
r 0 the basis for the alleged exemption.Any violation of Suction 7031.5 1 STORIES TYPE CONSTR.
5,: any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5,00
of not more Ihan five hundred dollars(55001.1:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
OCC.GROUP RES.UNITS
their sole compensalion,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and PrnlessRuns DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner o1'
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 so.FT.FLOOR AREA TOTAL ACREAGE
• melds arc
notth,intends ownprovidedforssle.11,edthctsueh improve- GAS-EA.SYSTEM-l 6.00
mems arc not intended or offered for sale.11,ed that S the building
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that hu did not build or iIn-
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
O 1,as owner of the property,am exclusively coNmcting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Coda:'Ihe Contractor's Licunso Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contmets for such projects with a contractors)licensed pursuant In
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 WATER HEATER W/VENT 6.00
reason
Owner Dam WATER SYSTEM - 5.00 ACC.DATE ACG FILE NO.
WORKERS'COMPGNSA1'ION DECLARATION WATER TREATING EQUIP. 5.00
I herchy affirm that l have a certificate of consent to self-insure, ZONING ENG.SITE NO.
cerlificule of Workers'Compensation Insumncc,ora certified
copy the of Sec 3800 Lab C.).
roln, N` C.�90 OrBlranr-R4g-public-1ndemn
Ce'lilic or shee forms d. FIRESPRINK ENERGY T-24
Z_ Z '1•S CeRih y is Bled i11111 it in mollµ.- I division, MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
O Applicant _ V N V N
~ va PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.c.
� CER"I'IFICA'I'E OI'Ii XEN1N ION I7RONI WORKERS'
UJ _ COAf I'ENSATION'INSURANCE PLG.CONTR. LIC NO. PLG.
d ❑
This section need not be completed if the permil k for one TOTAL Y❑ N❑ Y❑ N❑
Z) Z hundred dollars 1$100)or less.)
U O 1 DeRify that in the performance of the work for which this per QTV MECHANICAL PERMIT FEE FEE SUMMARY
LL F [fill is issued,I shall not employ any person in any Dinner so as Io
U become subject to the Workers'Compensation Laws of California.
U d Date Applicant - ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE 10 APPLICANT: 11,after making this Certificate o1'fix- _
♦- ? emplion,you should become subject to the Workers'Compenvliun 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
CONS'I'RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MIC.F.M.) 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. HEATING UNIT(TO 100,000 B.T.U.) 6.00 MICROFILM
Lend,civ C.). NO Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all oily and county PLUMBING
oRhFrnces and slate laws relating to building construction, and BOILER-COMM H.P.or 100,000 B.T.U.) 6.00
Hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 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 a finst liabilities,judgnumis, costs and cxpunses which CONST.TAX
may in an way accrue ugninst said City in mns.1 enee of the PERMIT ISSUANCE 10.00
rami 6 of his permit. MECH.CONT. LIC.NO. MECH,
6x TOTAL TOTAL
Signal eo Applicant/Contracor Dol
OFFICE COPY