18551 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
+� BUI LD1 NG PROJECT I DENTI FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 18551
7 RE S
' f BUILDING -ELECTRICAL-PLUMBING-MECHANICAL _�
0 ER'S 1 PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
• PHONE
CONT ACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00 1 0 Z < / "A
NAME //�� //''`` � / Lv
y .U- HiQ LSCO3
LIC.NO. ,3 LIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRE)ss
PHONE9883 PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION ,
ADDRESS
ZIP TEMP.METER OR POLE INS. 20.00 /
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 Lit .4V
ta
o O ey
LICENSED CONTRACTORS DECLARATION
W.w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
H G m (Commencing with Section 7000)of Division 3 of the Business and !r BLDG. ELECT. PLG. MECH.
r h z Professions Code,and my license is in full force and effect.
z O m - License Class Lic.Number.
o N H w Date Contractor
BUILDING PERMIT
City of
AYYwbn^
rc w a OWNER-BUILDFR DECLARA'I[ON INFORMATION
wodD MISC.- REFER TO ORD
LL I hereby a(linn lhol I um exempt from the Contractor's License
LL o¢ Law for the following reason.(See,7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
L- - 0 Code:Any city or county which reyuiresu permit to construct,alter, 'v 9000
RQ p improve,demolish.or repai,any sNut,orc,prior to its issuance,also EIEC,CONTR. LIC.NQ ELEC. .{� / v
O u requires Lire applicant for such permit to filen signed statement that TOTAL /�. VI PERMIT TO
a wPer he is licensed pursuant to the provisions of the Contractor's License
F z a
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe YL I ke�`� '
4 o Business and Professions Codchor that he is exempt therefrom and GTY. PLUMBING PERMIT FEE
¢ 4-
.0 the basis for the alleged exemption.Any violation Ill Section 7031.5 STORIES TYPE CONSTR.
n , by any applicant lira permit subjects the appllcauttoaceil Peealty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundreJ dollars(5500)-):
❑ 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 I'or sale (See 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND, 5.00
Code:'rite 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 5.06 S0,FT,FLOOR AREA TOTALACREAGE
. otept,re not
own cmployccssle.[1,providedthatsuch improve- GAS-EA.SYSTEM-11NC.4 OUTLETS 6.00
menta ore not ugh tit d or nfIcHidemplo lir sole IL ed that s the mpro e-
ro improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of Proving that he did not build or im- RES IND CON PB Omer
prove for purpose ofsalc.). INDUSTRIAL WASTE m INTER. 30.00 E] ❑ ❑ ❑ ❑
❑ I,as owner ol'the property,uexclusively contracting with
licensed contractors to construct the project (Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an..net of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA,) 1.00
con Totts for such projects with a contmctor(s)licensed pursuant to
the Col lactor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&PT.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSA"PION DeCLARA'I'[ON WATER TREATING EQUIP. 5.00
I hereby affirm that l have a certificate of consent toself-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lah.CJ.
Polity No. Company
O ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is tiled with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y ❑ N❑ Y EJ NE]
CC y CERTINCATE OP EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y El N❑ v C] N❑
IL O 11 his section need not be completed if the permit is for one TOTAL
Z) Z hundred dD1lars($100)nr less.)
U O I certify that in the performance of the work for which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is iss ed,1 shall n t employ an��p�%e('o�J/n/s/�'�1jpin an once,so as to
Ow Inccno yytlAi ' t tlhe Wnrkc,s' IIILyJL� La if S ifnrme.
a Data /_WW Applicant ALTER OR ADD TO MECH. 5.0 Q BUILDING I (�O
} m NOIICI'-T AI' LICANT: 11,alter making this Cenificme of Ex-
F Z emption,you should become subject to The Workers'Conhpensation APPLIANCE 5.00 PLAN CHECK
Provisions of the Labor Codc, you must forthwith comply with FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 4.00 n
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE 1 / �
1 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(See. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
r I certify thu11 have read this application and slate that(he 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-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorim representatives of this city to enter upon the BOILER-COMP love,100,000 BTU)SEE FEE SCM. MECHANICAL _ 40
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 PERMIT ISSUANCE 10.00 /2.&f CONST.TAX _
ay in any way come against said City in Consequence of the
To is' il. MECH.CONT. LIC.NO. TOTAL 40 TOTAL
Q may L/J
MECH
Signature of pelican T/Conlmdor to
OFFICE COPY
- i1