17361 (2) APPLICANT TO FILL IN INFORMATION'WITHIN RED LINES.- USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION - PERMIT NUMBER.
BUILDING APPLICATION & PERMIT ;' I'
ADDRESS BUILDING-ELECTRICAL-'PLUMBING-MECHANICAL : .17 3 61
O NER'S I - PLAN CHECK VALIDATION
QTY. ELECTRIC PERMIT FEE
CONTRRCTOA
NAM '7qq-�s/ UTLETS-SW_ITC HES-RECEP 10.00/1.00
IC.NO. 3VL.(o LIGHTING FIXTURES 10.00/1.00
r-DNTRACTOR's [' PPLIANCES-RESIDENTIAL 4.00 ( "? 9
AOO - (' 'p�jjJ`St' y.�dV/�� PANELS WOO • DATE OF APP ILCAYI N .^'
ARCHITECT sl.�l�/�C/•.�NRJ�lsE�. d�/ PLAN CHECK FEE P.C.NO.
OR - PANELS (OVER 200 AMP) 20.00 • -
ENGINEER
' LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENG.
SPECIAL CIRCUIT 5,06 PERMIT VALIDATION
zlr EMP.METER OR POLE INS. - 20.00 J � v k_IPNNA
ADDRESS MOTORS SEE FEE SCH. - -
ADDRESS
SER O N E 20.00
1na
w o OZ LICENSED CONTRACTORS DECLARATION
a
'.0 1 hereby of irm that I am licensed under provisions of Chupler 9
w a"' (commencing with Section 7000)of Uivisiun 7 of the BusinessylA BLDG. 'MECH.
FDi Professions Cos��jsan��y license is in lull for 1t..•e/ O RICO"❑ r-d
o i l2 W License ass-LAN Lic.Numbe.,S I Q�(
Date EI o Contractor ii
DATE 57/2=/Iii
a ¢
OWNER-BUILDER DECLARATION BUILDING PERMIT
E 5 s U INFORMATION
X ;LL I- I hereby affirm that I am exempt tient the Contractor's License MISC.- REFER TO OflD
IL 0¢ Law for the following reason.(Sec.7031.5,Businessond Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
� -0 Code:Any city or county which requiresa permit to construct,alter,
IS Z¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
ce
S,
requires the applicant for such permll to file a signed statement that . TOTAL PERMIT TO
A w m m he is licensed pursuant to the provisions of the Contractor's License
Fi>
Law(Chapter 9(commencingwith Section 7000)afDivision 3 ofthe f
¢ Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
aro the basis for the alleged exemption.Any violation of Section 703 1.5 1 STORIES TYPE CONSTR.
aim by any applicant for a permit subjects the applicant on civil penalty ALTER-DRAIN&VENT-WATER (EA) 5.00
of not more than five hundred dollars(55000.): . -
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 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 DRAINS-FLOOR,ROOF,AREA,CONE). 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES,PER TRAP 5.00 sD.IT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SVSTEM-11NC.40UTLETS 6.00
mends are not intended or offered for sale.If,however,the building
Or improvement is sold within one year of completion,the owner. GAS-EASYSTEM-OVER 4 IEA.)' 2.00 BUILDING USE
-
builder will have the burden of proving that h .e did not build or im- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
111,as'owner of the property,am exclusively contraCling with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCELNO.
and Professions Code:The Contractor's Licerkc 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 contractora),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.]or this WATER HEATER W/VENT 6.00 -
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE N0.-
WORK Ii RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate ofconsenl to self-insure, ZONING
or a certificate of Workers'Compensation Insurmme ori a certif d ENG.SITE NO.
copy ther a 4r�q'/enr.ch".l. n f!/V.
Policy NA I Pant rdl{y_DIS�J
Q ❑ C rliticdc pyJjs fierchy io Icd. FIRE SPR INK ENERGY T24
Z Z ❑ Certific / is filed to the cit I 'tion division. -
O AlipBcant (.tet-� MISC.• REFER TO ORD. v ❑ N❑ v ❑ N❑
CC ����-- PERMIT ISSUANCE 10,00 FLOOD ZONE A.L.U.C.
CL CI'.RTIFICA'1'1;OI'17XEMPTION FROM WORKERS' -
L COMPENSATION INSURANCE PLG.CONTR. ❑c.NO. PLG. v
1 Cl This section need not be completed il'the permit is for one TOTAL E] N❑ v ❑ ry❑
Z. hundred dollars IS 100)or lessI
U O I certify that in the performance of the work for which this per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner ur as to
U become subject to the Workers'Compensation Laws of California.
0 i Date Applicant ALTER OR ADD TO MECH. 5.00 ' BUILDING
} y N01lCF.TO APPLICANT: If,after making this Certificate of lix-
L.. Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCYAIR HANDLING UNIT(OVER 1000C.F.M.) 6.00 ' SEISMIC FEE
I hereby affirm that (here is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for whlc this permit is Issued(Sac. - MICROFILM
7097,Civ.C.1. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name0W HEATING UNIT(OVER 100,000 B.T.U.)9.50 -
Lender's Address. ,v ELECTRIC
1 certify that 1 have read this application and slate that(he above VENTILATION FAN (SINGLET 4.00 -
. information is correct. I agree to comply with all city and county -BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of (his city to enter upon (he BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL Alg -DD
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 roD CONST.TAX
ma in way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
at is perm' . MECH.CONT. LIC. MECH. '
j' TOTAL �6 00 TOTAL
nature of A pplican t/Contractor Uote r
OFFICE COPY