18406 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDING PROJECT I DENTI FICATI ONPERMIT NUMBER
BD,LD,NG APPLICATION & PERMIT Q A 0 C
A,
�J �} p
1S ',Dn W BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME 5^'j(.S-3y 'O QTY. ELECTRIC PERMIT FEE n
CONTRACTORS CQ PHONE $/06-037 JVI('/� ' S
NAME
rvamE OUTLETS-SWITCHES•RECE10.00/1.00 L
LIC.No, LIGHTING FIXTURES,-- 10.0011 GO
CONTRACTOR'S
ADDRESS PPLIANCES-RESIDENTIAL 4.00
PHONE PANE LS b 10.00 D 1.F AP ICA oN
ARCHITECTACHE K FEE .N
OR PANELS (OVER 200 AMP) 20.00 �,yT
ENGINEERS 1 (� Y
'I,gS,�„l rM. No. SIGNS TRANS. 3.00
ARCH.ORENG. P MIT ALIDA O
ADDRESS �r '}�� SPECIAL CIRCUIT 5.00 U; .Z
�S , Z,P W30 TEMP.METER OR POLE INS. 20,00 (^
APPLlcprvra
ADDA
APPLICANT
MOTORS SEE FEE SCH.
pjUCe1N�
S\ ,gU SERVICE CHANGE 20.00
a
OD 2 NJv3r��'Us�/WX�l \lY
HLICENSED CONTRACTORS DECLARATION
a i w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
r- ¢ 'm (commencing with Section]000)of Division 3 of the Business and
P, B2 CECT. PLG.
y z Professions Code,and my license is in full force and effect. MECH.�I
z O un - License Class Lm
ic.Nuber
4 r w Date Contractor
Q y f
a as OWNER-BUILDER DECLARA'I[ON BUILDING PERMIT
0 a OINFORMATION
w ;LL y I hereby allirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
FU04 Law for the followingmason.(Sec.7031.5,0usinessund Professions PERMIT I SUAN _t"o VALUATION $/FT.
mj Code:Any city or county which requires a permit to construct.alter, x �/ QQQ. IgA�2
Q ¢ p improve,demolish,or repair any strict Lire,prior to its issrtance,also ELEC.CONTR. , LIC. ELEC. I�
n wD LL. requires the applicant for such permit to file a signed statement that TOTAL��\� PERMIT TO -
m he is licensed pursuant to the provisions of the Contractor's License O
H Z Q
Law(Chapter 9(commencing with Seel ion 7000)of Division3 Little h' A )-r/
i 4 D Business and Professions Code)or that he is exempt therefrom and QTY. II, �L'MBI13G PERMIT FEE -
M I-$ the basis for Ore alleged exemption.Any violation of Section 7031.5 ` t V� STORIES TYPE CONSTR.
a ;- by any applicant for a permit subjects the applicant toacivil penally N ENT'WATER IEA.) 5.00 ^ ,4-�s
of not mora than five hundred dollars(S500).): ALT 'D 11' 6 JA W
O I,as owner of the property,or my empl oyecs with wages as SACK' LL W R TELT;DEVI q E 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 Profticrions DRAINS FL00 ,ROOF R OND. 5.00
Code:The Contractor's License Law does not apply to an owner of (Vproperty who builds or improves thereon,and who does such work FIXTUR. S-PER TRA w/
5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- r�
Plants arc not intended or offered Icor sale.11LL,however,the building GAS-'EN.SYSTE -1 IN . OUTLETS 6.00 LtZO 11 g3 tp
or improvement is Sold within one year of completion,Due owner- GAS-EASYSTE V (EA.) 200 BuaDING USE
builder will hose the burden of proving that h .e did not build or im- . RES IND CON PB Omar
prove for purpose ofsale.). INDUSTRIAL WASTEII�IJTE 30.00
I,as owner of the property,am exclusively contracting with - ❑ ❑ ❑ ❑ ❑
/ licensed contractors m mConbl the project ISec.7044,etHaShIlls
apply LAWN SPR INKL S- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Codec The who
builds o License s th docs net apply
to tr owner of property who builds tr improves thereon.and who LAWN SPRINKLERS -OVER 5 IEA.) 1.00
contracts act
ar'shcenjenswi,hucommdorlsl licensed pursuant,o SEWER-SANITARY-STD RM EA.200ft110.00
the Con[rncast s License Law. TRACT N0. PARCEL N0.
❑ lam exempt under S".-,IL&P.C+Inr this WATER HEATER W/V NT 6.00 sD
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILENO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby albrm that I have a ocnif ieule of consent In sell'-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T24
Z Z ❑ Certified copy is BIei with the city inspection division. -
O Applicant MISC.• REFER TO ORD. Y ❑ N[-] Y [-] N[_]2 y CERTIFICA'I'li Oh 8XE.%IPTION PROM WORKERS' PERMIT ISSUANCE 10.00 pO FLOOD ZONE A.L.U.C.
LU �_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL 0 This section need not be completed il'the Perini, Is for one TOTAL 7ja� Y[:] N❑ Y [:] N❑
Z hundred dollen IS 100)or less)
U O 1 certify that in the Perfm
orance of[he work Icor which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL l- mit is issued,I shall not employ any person in any manner so as to
Q w become sub'ect to the Workers'Compan. tion Laws of Cal i Porn ia.
y b: --IM Applicant- ALTER OR ADO TO MECH. 5,00 BUILDING 5901
} so NOTICE '1'0 APPLICANT: If,alter,n3 ,ng Ih,s Ccrl,l,calc nl fix-
? mutation,you should hecome subject to the Worken'Compensation APPLIANCE 5.00 ('� PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or[his permit shall be deemed revoked AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION•1.17NDINOAGENCY AIR HANDLING UNIT(OVER10=C.F.M.) 6.00 SEISMIC FEE Q3
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is Issued(Sec. MICROFILM
3097,Civ.C.L 1A HEATING UNIT(TO 100,000 B.T.U.) 8.00 4-��
Lender's NamAdders HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 S J"''
Lender's Address ELECTRIC J
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-WMP(3 H.P.Or 100,000 B.T,U.) 6.00
hcleby authorinc representatives 0[ this city in enter Imran the BOI LER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly 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 10.00X7,-a) CONST.TAX
- may in any way accrue against said City in consequence of the
Looting of this permit MECH.CONT. LIC.NO. MECH.
TOTAf TOTAL
8hgnalure of Apphcam/Contrado Uate l
OFFICE COPY