14586 (5)✓% Ar ICANT TO FILL IN INFORMATION WITHIN RED LINES•,= USE BALL POINT PEN ONLY
- 4BUI LDING PROJECT I.DENTI F16ATION
APPLICATION &PERMIT
BUILDING — ELECTRICAL— PLUMBING — MECHANICAL
-.PERMIT NUMBER _.
'
1�458�6
BUILDING
ADDRESS
.Z Al. $ J✓Z4' 81✓,
OWNER'S - �C' (y�✓ � C
" y/�(EE i,$ 1oS
/je/ I J/7Ml= PHONE
I
QTY. ELECTRIC PERMIT FEE
- PLAN CHECK VALIDATION'
'x/ s-�
°
c RACTOR
NAM ' QIJ FI iM
OUTLETS -SW ITCHES ';R SCEP 10.00/1'.00
LIGHTINGFIXTURES '10.00/1.00
-
"
DATE OF APPLICATION
PLAN CHECK FEE, -' P.C: NO.
- -
CONTRACTOR's ADDRESS
7/ I"*9/N�S X);4 PHONE �] —�L3
ARCHITECT `N
OR LL
ENGINEER
uc. NOLO/%a7
APPLIANCES- RESIDENTIAL " '4:00
PANELS 10.00
PANELS (OVER 200 AMP) 20.00
n
SIGNS TRANS. 3.00
ARCH.ORENG. ✓
ADDRESS 1 7,7 Z.
YFjQ S',EA�Or7 L'}- ZIP
$p ECIAL CI RQU IT 5.00
,'
PERMIT VALIDATION'
'
so
-•
EMP. METER OR POLE INS.- 20.00,.
APPLICANTS I9,MOTORS
ADDRESS
Y1'�9>L w TSL �Y Ndry.Y
. SEE FEE SCH.
-
d SERVICE CHANGE .20.00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that am, licensed under provisions of Chapter 9
NCE DATE
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
License Class Lic. Number
-
L T. PLG. MECH.
El 1-1
Date� 3 ( _Cont me to, ���
OWNER-RUILDER DECLARATI
I hereby affirm that I so exempt from the Cross and Pr License
Professions
Law for the following reumn.(Sec.uires ape itto
Code: Any city or county which requirese permit to consuact.alalter,
Improve, demolish, of repair any sticture, prim to its issuance,
t I..
RMIT
UILDINGPEION,
INFORMATION,
MISC.— REFER TO ORD
VALUATION
$/FT.
PERMIT ISSUANCE ' - --10.00
ELEC. CONTR. LIC. NO.
ELED.
that
nedp u applicant for tiro permit ns file a signed statement that
requires ilicensed
he is licensed pursuant m the provisions of the Contractor's License
Law (Chapter 9(commencing with Section 7000) of Division 3 ofthe
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5
°
NOTAL
PERMIT TO
110, IMPROVE.'
QTY. PLUMBING PERMIT - FEE
STORIES
TYPE CONSTR.'
ENT -WATER 5.00
ALTER -DRAIN '
- by any applicant for a permit subjects the applicant toa'civil penalty
ofnot more than fivebundmd dolrs($500).):
- "
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
intended or offered for sale (Sc,. 7044, Business and Professions
BACK FLOW PROTECT. DEVICE' 4.00DCC.
GROUP
RES. UNITS
,
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
Code: The Contractor's License Law does not apply to an owner Of
property who builds or improves.thercon, and who does such work
FIXTURES - PER TRAP 5.00
80. FT. FLOOR AREA
TOTAL ACREAGE .
himself or,through his own employees, provided that such improve-
ments are not intended or offered for sale. If, however, the building
'or improvement is sold within one year of completion, the Owner -
builder will have the burden of proving that he did nal build or int-
prove for,purpose of sale.). -
to I as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Sec. 7044, Business
'
(EA.)
RES IND CON - PB Omer
❑. ❑ El El ❑
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
-.'ASSESSORS PARCEL NO.
and Professions Code: The Contractor's License Law does not apply
to as owner of property who builds or improves thereon, and who
LAWNSPRINKLERS -'OVER 5 (EA.) 1.00
contracts for such projects with a contractors) licensed pursuant to
tlieContractor's'LicenseLaw.
-
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO,
PARCEL NO.
WATER HEATER W/VENT 6.00
.D I am exempt under Sec.—, B.&P.C. for this
reason
Owner - Date
WATER SYSTEM 5.00'
ACC.DATE
-
ACC. FILE NO.
WORK ERS'COMPENSATION DECLARATION
WATER TREATING EQUIP. 5.00 .
I hereby affirm that 1 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.C.) A/V-
,ld
Policy Ncu Company'
0 Certified copy is ]torch furnishe.
❑ CertifiErP.bpy is fA€d wi01 a sit inspection dlvlsimt
Applicant �1 i� t�_�/yyl 1—
�-
@
-
FIRE SPRINK
Y ❑ . N ❑
'ENERGY T-24
.y ❑ N❑
MISC.. 'I REFER TO.ORU
..
�_o
CHRTIFICAfE OF EXEMPTION FROM WORKERS'
PERMIT ISSUA E '`. x5;10'.00'
FLOOD 20NE
A. L.U.C.
PLC. CO NTR. LIC. NO. -
PLG.,
TOTAL
COMPENSATION INSURANCE
('This section. need not be completed if the permit is for one
Y ❑ N ❑
Y'❑ N ❑
OTY MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars ($100) or less.)
I certify that in the performance of the work for wlueh this per-
mil is issued, I shall not employ any person in any manner so as to
become subject to the Workers' Compensation Laws of California.Date Applicant
1O APPLICANT: II, after making this Certificate of Ex- emption, you should become subject to the Workers' Compensation
provisionsof the Labor,Code, you must forthwith comply with such provisions or this permit shall he deemed revoked:
CONSTRUCTION LENDING AGENCY
ALTER OR ADD.TO MECH. 5.00NOTICE
APPLIANCE 5.00
- AIR HANDLING UNIT (TO 10=C.F.M.). 4.00
AIR HANDLING UNIT(OVER IO,OODORM.) 6.00
FFEE
'7II
EXHAUST HOOD (WITH DUCT) 5.00the
hereby affirm that there Is a construction lending agency (or
performance of the work for which this permit is issued (Sec. 3097, Civ.CJ.
HEATING UNIT(TO 100,000 B.T.U.) 8.00
UNIT(OV ER 100,000 B.T.U.) 9.50
_
Lender's NameHEATING
Lender's Address
it that l have read this application and state that the above.
VENTILATION FAN (SINGLE) - •-4.00'
certify
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction; and
PLUMBING
.
BOILER-COMP(3 H.P. oT,100,000 B.T.U.) 6.00
g01LER-COMP (0,g, 100,000 BTU) SEFr.FEE SCH.
.MECHANICAL
lidrehy authorize representatives of this city to enter upon the.
above-mentioned property for inspection purposes.
'rfWe) agree to save, indemnify and keep harmless the 'CBY of
upertino against liabilities, judgments, costs and expenses which
ma any wny'aceruc against said City in consequence Of the
mn[' g any w IL p
_
MISC.= - REFER TO ORD.
CONST. TAX
-
PERMIT ISSUANCE 10.00
.. - -
MECH. CONT. LIC. NO. -- - MECH.N"t
TOTAL'TOTAL
070
.pi ✓(' Weki e' 2-Z-'
Ig -tore of Applicant/Contractor Date
OFFICE COPY