14664 (3) ,APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
• BUILDING PROJECT IDENTIFICATION - PERMIT NUMBER -
A^DDR^Es^S APPLICATION & PERMIT
1 VfL , AVC CuP&y2_rlry BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 14664
OWNER'S (��I -/.✓ -fill PLAN CHECK VALIDATION
NAME �V J OTV. ELECTRIC PERMIT FEE Q -
A►.� nkon, w ( PHCONT "c as2-G33
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NAME croRs UTLETS-SWITCHES-RECEP 10.00/1.00 NAME
LIC.No, LIGHTING FIXTURES 10,00/1.00
r-Oera.croas -
CONTRAS PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10,00 GATE OF APPLICATION
ORDH,TEcr PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
EOR
eec. - SPECIAL CIRCUIT _ 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 - - -
APPLICANTS MOTORS
ADDRESS SEE FEE SCH.
SERVICE CHANGE 20.00
0 Se z t,L/d's//pp
F o o IJCENSED CONRACfURS UIiCLARA'f10N / 7 0
a i w I hereby affirm that I am teemed under provisions of Chapter 9 ISSUANCE DATE
r
(commencing with Section 7000)of Division 3 of the foxiness and n a cBLDG. ELECT. PLG. MECH.
0 i LicenProfese Clu Code,and my license . In full force and c fed. ❑
IET
a o License Class Liu.Number
o N H o Date Cont Tactor p -
a Y m LI c BUILDING PERMIT
¢
or w a OWNER-BUILDER DECLARAT1oN ORMATION
R
S LL I- I hereby affirm that I am exempt from the Contractor's License
MISC.- REFER TO ORD
r• Ic o o, Law for the following reasum(Sea 7031-.5,Businessanci Professions PERMIT ISSUANCE tON 5/FT.
Code:Any city or county which recluires i Pcruit to construct,alle, 10'� •f ,�n
a ¢ ¢ o improve,demolish,or repair any strudum,prior to its issuance,also ELEC.CONTR. LIG NO. ELEC. CX J _
¢ requires the applicant forsuch permit to file a signed statement that TOTAL PERMIT TO
K
he is lieenscd pursuant to the provisions of the Commctoh Licenv "_79
F a a Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 0 Business and Professions Cods)or that-he is unempt therefrom andQTY, PLUMBING PERMIT FEE �NlOQ O!�
or I- $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a Peron subjects the applicant to.civil penalty
of not mom than live hundred dollars(S5000 3 ALTER-DRAIN&VENT-WATER (EA.) 5.00
0 I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 DCC.GROUP RES.UNITS
their sole compensation,will do the work.and the structure is not
intended or offered fur sale (Sec 7044, Business and Prolessions DRAINS-FLOOR,ROOF,AREA,CONO. 5.00
Code:The Contractor's License Law does not apply to an owner of
=,ty,wha builds or improves thereon,and who does such work 3 FIXTURES-PER TRAP 5.00 SO.FT FLOOR..EA TOTAL ACREAGE ,
himuh or through bis use,,employscs,provided that ueh inmrovo
merits are not intended or offered for sale.It,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
(�Vy builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose U sale.). INDUSTRIAL WASTE INTER3000 RES IND CON PB oma
. .
❑ I,as owner of the property.am exclusively contracting with ❑ ❑ 0 ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Cod,The Contractor's License Lw does not apply
to an us,7,of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed purwmt to
the Contractor's Licen w. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam cxcn ,B.&PC tort is WATER HEATER W/VENT 6.00
Tensor
caner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKbRS'COMIIbNSA1ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of conserr to sel&insa,.
or a certificate of Workers Compensation Insurance,or a certified ZONING ENG.SITE NO,
copy thereof(See.3800,Lub.C.).
Policy No. Compmy
O ❑ Certified copy is hereby furnished RE SPRINK ENERGY T-24
Z Z G1 Certified Copy is filed with the city inspection division.
O Applicant MISC.- REFER TO ORD. Y❑ N❑ Y I] NE]
E-
f2 w CERTIFICATE 0171 XEMPTION DPERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
RUM WORKERS' Q �
W > COMPENSTIto
AON INSURANCE PLG,CONTR, LIC.NO. PLG.
d 0 (This section need not Be completed if the permit is for one TOTAL O Y❑ NE] Y 0 N❑
Z hundred dollars[$I00)or less I
U O 1 cunity that in the p,rlornsance of the work for which this Pur- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
1L U mit is issued,I shall not employ any person in any manse,So as to
Ow become subject to the Workan Compensation Laws of California.Da�a
D.(.-Applicant BUILDING ALTER OR ADD TO MECH. 5.00
} Go NOTICE '1 O APPLICANT'. If,after making this Cenificatc of Ex-
emption,you should become u,bject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provstons of the Ubor Code,you most forthwith comply with FEE
V such provisions or this pemtit shall he deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M,) 6.00 SEISMIC FEE
I hereby affirm 0,m there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued fSee. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 oL'�a_
�y Lender's Address ELECTRIC
la:�-+•aF>j3 I certify that 1 have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
�L infnrmmion n cornet. 1 agree ti comply with all city and county PLUMBING O�
V lonelyces and stow laws alive ng to building carne, ion, and BOILER-00A'P(3 H.P.or 100,000 B.T.U.) 6.00
1 hereby antionee representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
as��;/ aborc-mentioned property for inspection purlwses.
. (We) agree to save, indemnify and keep limmlm the City of MISC.- REFER TO ORD.
-- upertino ag.imit liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in a�an,/C
in Consequence of the
sting oMECH.CONT. LAC.NO. MECH, l
LZ TOTAL TOTAL
Setifaturt ac
OFFICE COPY