16413 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES USE BALL POINT PEN ONLY
BUILDI NG PROJECT IDENTI FICATM I PERMIT NUMBER
BUILDINGAPPLICATION.& PER* q ^ 1
ADDRESS / OI� LFG D. I '{
L BUILDING — ELECTRICAL-,PLUMBING —MECHANICAL - sep
UVVNeu'B PLAN CHECK VALIDATION
NAME �, 1 _ '. OTY. ELECTRIC PERMIT - FEE
NPHONE
CONTRACTORS' OUTLETS-SWITCHES-RECEP 10.00/1.00 r
S C.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'E
�>e�si - APPLIANCES-RESIDENTIAL 4.00 - a
„ JJJ -PHONE j8=y p PANELS 10.00 DATE OF APPLICATION 1:r
ARCHITECT PLAN CHECK FEE - P.C.NO.
OR . PANELS (OVER 200 AMP) " 20.00 , -
"
ENGINEER t
LIC'NO, SIGNS TRANS. 3.00AD H,OR C '
ADDRESS ENG. SPECIALCIRCUIT 5.00 PERMIT VgLIOATION -
zaTEMP.METER OR POLE INS. 20.00
APPLICANT'B - MOTORS - SEE FEE SCH.
- ADDRESS "' �
_ SERVICE CHANGE 20.00
w o o LICENSED CONTRACTORS DECLARATION
¢ a, u I herebyaffirm that I am licensed Linder rovbioos of Cha filer9
y a i
(commencing Ing with Section 7000)of Division 3 of the Business and IbBUq NCE DATE ) ""
H i Professions and y icense is in full force and effect. '
J BLOG. ELECT. PLG.
icen -:MECH.
zo i w o Ls lasss _ — m.Numbe
Cr - . . �
T F Data' onl actor,
¢ >! SJ BUILDING PERMIT
E IS w OWNER-BUILDER DECLARATION
a oA INFORMATION
X 3 N I hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD -
LLD ¢ Law for the following reason.(Sec.703L5;Businessand Professions VALUATION $/FT.
— w � Code:Any city or county which requires a permit to construct,alter, PERMIT ISSUANCE 10.00
r
Q'p ¢ � improve,dCInOI1SI1,nrrepair any Stfne Wle,prior to 115 R54ance,also ELEC CONTR. LIC.NO. ELEC:
0,u requires Ile applicant for net,permit to file a signed statement [,at - TOTAL PERMIT TO ,
a
is es y he Is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000)ofDivision 3 oflhe
C 4 O Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ 1- m the basis for the alleged exemption.Any violation ofSection 7031.5 STORIES TYPE CONSTR.
a3 by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN (EA.) 5.00 '
of not mom than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.'.DEVICE 4.00 Oce.GROUP REB.UNITB
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sea 7044, Business and Professions DRAINS-;FLOOR,ROOF,AREA,CON D. 5.00 '
Code:The Contractor's License Law does not apply to an owner of - -
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP' D.PT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve 8
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11N C.4 OUTLETS 6.00 19 V
or improvement is-sold within one year of completion,the owner-
builder will have the burden of proving that Ile did not build or ins- GAS-EA.SYSTEM:OVER 4(EA.) 2.0 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.06RES QD Dory PB Omar,
❑ I,as owner of the property,am exclusively contracting with - - q1 � ❑' ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLER$=1 ING5 V,B. 6.00 `] ASSESSORS PARCEL NO.
rAT
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds,or improves thereon,and who LAWN SPRINKLERS,OVER 5(EA.) 1,00
contracts for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 - TRACT NO. PARCEL No.
❑ I am exempt under Sec.—,BAP.C.for this
reason WATER HEATER W/VENT
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION 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 a certified _ •ZONING ENG.SITE NO.
copy thereof(Sec.3800,•Lab.CJ. v
I Policy No: Company _
.0 ❑ Certified copy is hereby furnished. - FIRE SPRINK ENERGY T-24
Z Z ❑ Certified,copy is filed with the city inspection division ❑ ❑ N❑
F 0 . Applicant MISC.- - , REFER TO ORD. Y [:] NYl
CC CERTIFICATE OF EXEMPTION.FROM WORKERS' .. PERMIT ISSUANCE p` _ FLOOD ZONE A.L.U.C.
"UJ COMPENSATION INSURANCE ?LG.CONTR. LIC.No. TOTAL= lY,❑' N❑' . v,❑ N❑
1 (This sectom need not he completed it the permit is for one '
Z hundred dollars($IXdor IessJ - -
U 0 I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued.I shall not employ any person in any manner so as to
V nee �g sqb' c({ he Workers' a salion Laws of California. -
i Date�Applicanl - BUILDING
} m NOT CE Tbb APPLICANT: If,after making this Certificate of lix- ALTER OR ADD TO.M MECH. 5.00
F. 2 emptlon,you should become subject to the Workers'Compensation a APPLIANCE - 5.00 PLAN CHECK
-
provisions of the Labor Cade, you must forthwith comply wills
U! such provisions or this permit shall be deemed revoked. AIR,HANDLING UNIT(TO 104000.F.M.) 4.00 FEE ,
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE '
1 hereby affirm that there is a construction lending agency far : EXHAUST HOOD (WITH DUCT), 5.00 -
y the performance of the work for which this permit is Issued(Sec. MICROFILM `
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 "
Lender's Name H EATI NG UN IT(OVER 100,000 B_.T.U.)9.50
Lender s Address ELECTRIC
, Icertify list l have read this application and state shot the above VENTILATION FAN (SINGLE)" ' -!_ 4OD -v
information is correct. I agree to comply with all city and county PLUMBING (�
ordinances end state"laws relating to building construction, and
BOILER-COMP(3 H.P.or 100,000 B.T.U.1 6.00 .; '
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 160,000STIL0 SEE FEE SCH. MECHANICAL
above-mentioned property forinspection 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
may in any way seer a against said City in consequence of the 'PERMIT ISSUANCE 10.00
nting of thisp nth MECH.CONT.. - LIC.NO, t MECH.
�p TOTAL TOTAL
-� Ignature of Applicant Contractor Date .I
OFFICE COPY