3417 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PER ITN R
BUILDING APPLICATION & PERMIT _ __ ___ 417
ADDRESS `1 .`
YON BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S �1 ,v PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
NA"T CTORSOUTLETS-SWITCHES-RECEP 5.00/1.00
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J
-U-11I 1
uc.NO. LIGHTING FIXTURES 5.00/1.00
CONTRACTOR
A RE APPLIANCES-RESIDENTIAL 4.00
/]J�
PRONE ,3-0171�y
PANELS 5.00 DATE OF APPLICATION
ARCHITECTSIGNS 600 .PLAN CHECK FEE P.L.NO.
OR .
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH,OR ENG. SPECIAL CIRCUIT Fj,QQ PERMIT VALIDATION
ADDRESS
- ZW TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE - 10.00a(/y/�p
� 0o LICENSED CONTRACTORS DECLARATION / /o
< is U I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
r a i (commencing with Section 7000)of Division 3 of lir B siness and -BLDG. ELECT. PLG. MECH.
FD i Professions ad n ansa is in full for ❑
z o L License Clas Lia Number ❑
9 y.H Con Vacto
Q y s BUILDING PERMIT
a in w u OWNER-BUILDER DECLARATION INFORMATION
w ;LL y I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD - VALUATION $/FT.
F u. 0 j Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,alter.
Q ¢< improve,demolish,or repair any structure,prior to Its issuance,also ELEC.CONTR, LIC.NO. ELEC.
y w m n requires the applicant for such permit to file a signet)statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of lire Contractor's License
Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe .U�i B//x((.Y
a Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
M r$ the basis for the alleged exemption.Any violation of Section 703 t,5 STORIES TYPE CONSTR.
w. by any applicant for is permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
.of not more than five hundred dollars($5001.):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00'
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon.and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLET$ 4.00
Or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER'4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build Orion RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ ❑ [1 ❑ -
I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
t0 an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 IEA.) . 1.00
contracts for such projects with a contmetons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/6.00 TRACT NO. PARCEL No.
❑ I am exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 4.00 _-
on
Date Owner WATER SYSTEM4.00 ACC.DATE ACC.FILE NO.
WORKF.RS'COMPFNSATION DECLARATION WATER TREATING EQUIP. 4.00 �
I herchy affirm that 1 have a certificate of consent to self-insure, - ZONING ENG.SITE N0.
or a certificate of Workers'Comp`nsurno Insurance,o u certified
copy thereof(See.3800.Lab C.) .per-.,�sr .VJ
Policy No. Company n^JJ 1J1i1N {W
0 IDCertified copy is hereby furnished. FIRE SHRINK ENERGY T-24
❑ Certified co Fle ith the city inspection division.
z0 Applicant �` tSe7�1 MISC.- REFER TO ORD. Y ❑ rv❑ Y ❑ N❑
~ mMIT ISSUANCE 6.00 FLOGO ZONE A.L.U.C.�/
LU -
CERTIFICATE OF EXEMPTION PROM WORKERSPER
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ll.l � COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This section need not be completed if the permit is for one TOTAL D '� Y❑ N❑ Y ❑ N❑
=) Z hundred dollars(SI00)or less.)
U O 1 certify that in the'perfunnance of the work for which if...per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
'LL F mit is issued.I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
Date Applicant BUILDING
} tai) NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 4.00
L.. ? emption,you should become subject to the Workeri Compensation APPLIANCE 4.00 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)000CF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
tint, performance of the work for which this permit is issued(Sec. MICROFILM
3097;Civ.C.). I HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name H EATING UN IT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC S
I certify that I have read this application and state'that the above VENTILATION FAN (SINGLE)- 3.00 - a
information is correct. I agree to comply with all city and county .PLUMBING /� '•� 'n
ordinances and state laws relating to building construction,and BOILER-COMP M H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100L000BTUI SEE FEE SCH. MECHANICAL
sbove-mentioned prope for inspection purposes.
e a ec to a e demnify and keep harmless the City of MISC.- REFER TO ORD.
upertino gains&CS,judgments, costs and expenses which CONST.TAX
in a y wagainst said City t consequence of the PERMIT ISSUANCE 3.00
iant) -f this p/ MECH.CONT. LIC.NO. MECH. TOTAL /O�/
Cy OTA
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Sign re of Applicant/G or Dafe
OFFICECOPY _
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