18672 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENT[FICATIDN ' PERMIT NUMBER _
9uILOIrvc L` p Ia I APPLICATION & PERMIT 8672
ADD,E $
1 d1 �L<<E BUILDING -ELECTRICAL-PLUMBING-MECHANICAL n,
OwNER'SN US•1C �qIPLAN CHECK VALIDATIO
"AME AN O T QTY. ELECTRIC PERMIT FEE
C� Sfh f0ep PHONE 2
CONTRACTORS
NAME
' UTLETS-SWITCHES-RECEP 10.00/1.00
freV 9TCr/JES CCWSiI.ICNo �1 -/O6 LIGHTING FIXTURES 10.00/1.00
CONTRACTORS`!S-4RPPLIANCES-RESIDENTIAL 4.00
ADORE
p,e pq C,,r CA. PHD X33 73 91V3 PANELS 10.00 DATE OF APPLICATION
ARCHITECT�.oMyKLEe,�' ,. PANELS 200 AMP) 20.00 PLAN CHECK FEE P.C.NO,
DR 35
ENGINE R pp
LFBU$f IJ�.kuc.NoCwJ SIGNS TRANS. 3.00 I
ARCH.OR ENO. SPECIAL CIRCUIT S,OQ PERMIT VA AT ON
ADDRESS ^1 2 j 0.- I kA ST
LA S tAl'j1 zIP EMP.METER OR POLE INS. 20.00 Pi 0
Arrucarvrs;rr3 r1A.DHESS -,�� MOTORS SEE FEE SCH.
I -2.. SERVICE CHANGE 20.00 I G V 1 9 199
o o LICENSED CONTRACTORS DECLARATION p,�,� pp ��{{{{.�..��
Ix u 1 hereby affirm that I am licensed under provisions of Chapter 9 {FRT OF )Sb1taAd DATE
nQ H (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r N z Professions Code,aIXUmy license is in full farcy)IW e( •b 6�/
z O w - Leer Class_ //11 I.ic.Number_? /_ ! ❑ ❑ ❑ ❑
O - lmc�!3 a_Gmorsel.,
ars _a BUILDING PERMIT
w OWNER-BUILDER DECLARATION
0 4 MISC.- - REFER TO ORD INFORMATION
E
S � 1 hereby Alli, that 1 am exempt from the Contractors License
uoa Law for the following reason. 7031.5.Businessand Professions PERMIT ISSUANCE 10.00 VALUATION _I'$/F�T7.
r - Code:Any city or county which requires apermit to construct,alter, B/10 L�
SE u Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIAN[, E C. G Tt COO T`E�
DLL requires the applicant for such permit to file a signed statement that i OTAL IT TO
n w m he is licensed poOmen To the provisions If the Contractor's License
rzi Law(Chapter 9(commencing with Section 7000)of Division 3 fthe -L
a Business and Professions Code)or that he isexempt therefrom and CITY. P FEE
ce r-$ the basis for the alleged exemption.Any violation oftiection 7031.5 I TS STORIES TYPE CON@TR�@TR.
u by any applicant for a permit subjects the applicant too civil penally ALTS R-D &V E ER (E . STftL �lU
PS
of not more than five hundred dollars(4500).1: *-,o?_4 W4L
❑ 1,as owner of the property,or my employees with wages as BA F PRO EVICE OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions IN - 00 ,ARE N 5.00
Code:The Contractor's License Law does not apply to an owner.1'
1 property who builds or improves thereon,and who does such work FIXTU ES- TR P 5.00 $O,ft FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided that such ibuildi e 3 SL�O
himself are not intendis oroffered employee sale.provided
thathowever,the......ding GAS-EA. EM-11 4 UTLET 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-O ER 4 (EA) 2.00 BUILDING u5E
builder will have the burden of proving that he did not build or im- RES IND CON v0 Omer
,RvvV for purpose of snlcJ. INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ El El ❑
I,ns owner of the property,am exclusively contracting with
li •used contractors to construct the project(Sec,7044,liminess LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:"Pile Contractor's License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
co it for such projects with a sontmetur(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.fur this WATER HEATER W/VENT 6.00
reason
Owneryy LLI�aic 2 - WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO.
94.. ORAIiRS'COMIiNSAT1ON I CLARATPION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofeonsenl to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certilied
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
z Z ❑ Certified copy is riled will, file city inspection division.
O Applicant MISC.- REFER TO ORD. v ❑ N❑ v C] N❑
Cc: N CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LJ > COMPRNSA7ON INSURANCE PLG.CONTR. LIC,NO. PLG.
C O ('Phis section need not he completed if the permit is Ibr enc TOTAL Y❑ N❑ Y ❑. N❑
D Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mil is issued,I shall not employ any persue in any manner so as to
Ow becoom subject to the Workers'Compensation Laws of California. BUILDING
DateApplicant ALTER OR ADD TO MECH. 5.00 '
>_ w NOTICE 'l0 APPLICANT: If,after making this Certificate of Ex__
Z enption.you should..creme subject to Om Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply wit! FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10JJOOC.F.M) 4.00
CONS"FRUCT'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE 3 .�Q
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work lot which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.C,).
Lender's Name HEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
1 certify that 1 have read thus application and State that the above VENTILATION FAN (SINGLE) 4.00
infou,mcc, o correct. I agree to comply with all city and county BOILER-CDMP(3 H.P.or 100,000 B.T.U.) 6.00 - PLUMBING
oN...antes and sole laws re to c to building lconstruction,d co and
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 against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
,ay in any way accrue against said City in consequence of the
ranting of this permit MECH.CONT. LIC.NO, MECH.
. //J�+t'- . TOTAL TOTAL
Signaturee of Applicant/Contractor Date
OFFICE COPY