18569 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENPERMIT NUMBERTI FICATION APPLICATION & PERMIT 18569
BUILDING
AooREss
��Q_ D BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNEN'S /� /
PLAN CHECK VALIDATION
D
NAME � DTV. ELECTRIC PERMIT FEE
�1 /7� -2 0 • PHONE
CONTRACTOR'S
NAME �+ UTLETS-SWITCHES-RECEP 10.00/1.007 vU -
.g KLgCDaE'tcuG.N LIGHTING FIXTURES 10.00/1.00 Z.0
ADDRESSAC TOR'S PPLIANCES-RESIDENTIAL 4.00
CLY,121NE PANELS 10.00 DATE OF APPLICATION
OORcHITEc PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO,
ENGINEER
LIC,NO, SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP ITEMP.METER OR POLE INS. 20,00
ADORE Ts MOTORS SEE FEE SCH.
z Fyes SERVICECHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION sty I
a U U I herelly affirm that lam licensed under provisions Of Chapter 9 ISSUANCE DATE
wz w (commencingwith Section 70001 of Division 3 Of Rosiness'and
, w B G. ELECT. PLG. MECH.
r H z Professions Code,and m license is in full for d of c{, ❑ A, ❑ ❑
z O g - License Class_,C-,./-�Lic.Number �5.3r� IefY-�I--'
O l2 r a Date_(�a/f Contractor_j;s £�y-�Q(
ars RAT BUILDING PERMIT
IS M ¢ OWNIi R-BUILDER UECLARA'PION
s a, D INFORMATION
K
3 LL w I hereby ulfinn Dsat 1 am exempt from the Contractors License MISC.- REFER TO OR
g- PERMIT ISSUANCE 10.!- 1.e00 VALUATION B/FT.
r u D g Law for file followln reason(Sec.703 L5,Business and I'rofesslona00
Code:Any city or county which requires a permit to construct,alter, -
QLc ¢ o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELIC
O u requires the applicant for Such permit to file a signed statement that - TOTAL/s�1 PERMIT TO
A w m m ho Is licensed pursuant to the provisions of the Contractors License
>
Law(Cha ter 9(commencin with Section 7000)of Division 3 of the J}��+
E ¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE 4 1f-C,
¢H e the basis for the alleged exemption.Any violation of8ection 7031.5 STORIES TYPE CO TR.
i ';m by any applicant for a permit subjects the applicant o a civil penally ALTER-DRAIN -WATER IEA.) 5.00
of nol more than five hundred dollars(5500)):
❑ I,as owner of the properly,or my employees with wages as BACK F LOW PROTECT.DEVICE 4.00
their sole compensation, will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions 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(hereon,and who does such work FIXTURES,PER TRAP 5.Q0 50.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
Grentsare net intended oroffered for sale.If,however,file building GAS-EA.SYSTEM-I1NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or ice- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 3000 RES IND CON PB Other
.
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ Ellicensed contractors to construct the project(See. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCELNO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves Ihereon.:md who LAWN SPRINKLERS-OV ER 5(EA.) 1.00
Contracts for such projects with a contractor(e)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
❑ I am exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION UECLARA'MON WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to sell-insure, ZONING ENG.SITE NO.
or'a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
0 ❑ Certified copy is hereby-furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is Filed with the city inspection division. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
F O Applicant Y N V N
cc W CERTIFICATE OIr EXEMPTION I7ROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZDNE A.L.u.O.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO.CL0 PLG.
0 Z ('Phis section need not be completed if the permit is liar one TOTAL Y❑ N❑ v ❑ N❑
hundred dollms is 100)or less.)
U O I cerlity that in the performance of the work for which this per' OTY. MECHANICAL PERMIT FEE FEE SUMMARY
UL F hilt is issued,I slmll not employ any person in any manner so as to
0 L) baeomo subject�p the Workers'Com�wyupon Lows otwo,�'t
a.
} W PITIC p I: I --t!naki 0,
�rLl ALTER OR ADD TO MECH. 5.00 BUILDING
W NOT li' AI'I' ICAN'1': II',after making this Cerlix-
F ? empllon,you should become subject to the Workers' ation APPLIANCE 5.00 PLAN CHECK
provisions of DIe Labor Code, you must forthwith with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10000C.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10A00C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the,perlormance of the work for which this permit is issued ISec. MICROFILM'
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Nddr H EATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC UD
Icertify that l haverexd this application and Stam Dmt the above VENTILATION FAN (SINGLE) 4.00
information is correct.1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP I3 H,P.Or 100,000 B.T,U.) 6.00
hereby authorial, representatives of this city to enter upon the BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL
shove-mentioned property for inspection purposes.
(Wa) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
upertino against liabilities,judgments, costs and expanses whiclt PERMIT ISSUANCE 10.00 CONST.TAX
I, in any way accrue against said City,in consequence of Che
nmtingo this permit. - MECH.CONT. LIC.NO. MECH.
_ TOTAL TOTAL ,Q6
�u -
gnalureol'Applicant/Con or Date
OFFICE COPY