15427 (3) APPLICANT TO FILL'IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY -
,B1�ILDINGPROJECTIDENTIFICATION PERMIT NUMBER 1..
BUILDING APPLICATION & PERMIT
Y ADDRESS ,t„ 15427
JL� 9Lffi BUILDING -ELECTRICAL-PLUMBING -MECHANICAL
+>
GINNER 5 •�'•r - PLAN CHECK VALIDATION
;s "Ante QTY. ELECTRIC PERMIT FEE
1 I r PRONE
CONTRACTOR
•( rvnMEy s � Z_ UTLETS-SWITCHES-RECEP 10.00/1.00 d
L,T C/� C�oj�. ua N6. "�'�p - LIGHTING FIXTURES10.00/1.00
CONTRACTORS /� APPLIANCES-RESIDENTIAL 4.00
� ADDREss / .,tj'-R�•'i3 GvG�}
PANELS 10.00 DATE O F APPLICATION'.
ARCHITECT PLAN CHECK FEE PC
O ,NO.
DR PANELS (OVER 200 AMP) 20.00 _
ENGINEER
TIC.No, SIGNS TRANS. 3.00
ADDREss E"D' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP FEMP.METER OR POLE INS. 20.00 n '
Auis MOTORS SEE FEE SCH.
ADDRESS // �
L)CZ�/'�'ar-Lc f'ffh:- SERVICE CHANGE 20.00 '� p
�02 LICENSED CONTRACTORS DECLARATION /dfesO('//
,-- r
a u 1 hereby affirm that I am licensed under provisions OLChapter 9 ISSUANCE DATE
y ¢ v'Ai (commencing with Section 7000)of Division 3 of the business and ELECT. PLG. MECH.
ma y, Professions Code,' my lice Ise is in full t -•:y0e0 tII
O,.- License Cl ss Lic.Number' A
a w H °w. Dale I Cimeactor� 1y t( P .It:
�.
EE r 4 x..� BUILDING PERMIT
Ix 0 i U OWNER-0BUILDER DECLARATION - INFORMATION
I'xu ; LL Thereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
VALUATION $/FT.
u0 J Law for the following reason. 7031.5,Businessand Professions 1000 Q �
1- - g PERMIT ISSUANCE
Cope: e,demolish,
cue mywh icy structurepermi flocs issuance,
ELEC.CONTR. LIC.NO.
Se 2 a improve,demolish,or repair any structure,prior to its issuance,also ELEC. �-
aa D u requires the applicant for such permit to file a signed statement that TOTAL
a w m o. he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
> Law(Chapter 9(commencing with Section 7000).f Division 3 ofthe _ 1,��
F i c Business and Professions Coda)or that he is exempt therefrom and QTY. NT ���
PLUMBING PERMIT FEE J'� V
IS H m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
e- 3 by any applicant for a permit subjects the applicant to a civil penally
of not more than live hundred dollars($5000.): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ I,as owner of the property;Or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.
their sole compensation,will do the work,and the structure is not UNITS
intended .offered for sale(Sec. 7044, Business and Professions DRAINS-FLOORROOFAR EA,CON D. 5.00 a
Cade:rhe Contractor's License'Law does not apply to an owner of , ,
+ pmperty W ho builds or improves thereon,and Who docS such work / FIXTURES-.PER TRAP 5.00 � SO.FT FLOOR AREA TOTAL ACREAGE
himself,.,through his own employees,provided that such improv.
meni.if mi not intended or offered for sale.l L however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 6.00
or improvement Is sold within one year of completion,the owner.
L 'y builder will base the burden of proving that he did not build or int GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
V prove for'purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ I,as owner of the Property.am exclusively contracting with ❑ ❑ Q ID 0
licensed contractors to construct the project(Sec.7044,business LAWN SPRINKLERS-i INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs nal apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 -
contracts for such projects with a conlractods)licensed pursuant to SEWER-SAN EA.200ft/10,00
the Contractors License Law. TRACT NO. PARCEL NO.
- ❑ Pum exempt under Sec. ,b.&P.C.for this WATER HEATER W/VENT 6.00
reason'
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPEN'SATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have I certificate of consent to soli-insure,
on a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company -
O ❑ Certified Copy is hereby furnished. FIRE SPRINK ENERGYTI4
J Z ❑ Cerlillcd copy is fled with the city inspection division. MISC- REFER TO ORD.
I Applicant Y [] N� Y [:) NO'
~ rn PERMIT ISSUANCE 10,00 -
LU
CF RTI FICCOEPE I AI 1019 ION PROM WORKIiRS' U - FLOOD ZONE A.L.U.C.
W > COMPIiNSA'I'ION INSURANCE PLG.CONTR. LIC.N0. PLG.
CL 0 (This section need not he completed if the permit is for one TOTAL Y NY 0 N�
::) Z hundred dollars IS 100)or less.)
V O I certify that in the performance of-he we far which this per-
! QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shah not employ an p rson i a manner so as In
O W beco t_ the Workers'C ti L r ornia. a
W Dat m / _ Applicant ALTER OR ADD TO MECH. 5.00 BUILDING /7 •j
} W NOT1 E A PLICAN'T: II',a0cr making If,:Cenificate of h.x-
F'Z emption,you should become sobjeo t.the W keri Compensation APPLIANCE 5.00 PLAN CHECK
provisions M the Labor Code, yen mus( ' (hwith comply with FEE
C..1 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10A000.EM.) 6.00 .SEISMIC FEE '
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.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
- '
Lender's Address ELECTRIC
-1-
I citifycthat I have reap this application and state that VENTILATION F N
ppthe aboveA (SINGLE) 4.00
information is correct I agree to comply with all city and county PLUMBING
ordinances and state laws relating to huddi09 construction, and BOILER-COMP(3H.P.Or100000B.T.U.) 6.00 /
hereby authorize representatives of this city to colter upon'Ilie BOILER-0OMPIOver100.000BTU)SEEFEESCH. MECHANICAL S°t
above mentioned property for inspection pure, ,�
(We) agr to save, in certify and keep hutnreas the City of MISC.- -REFER TO ORD.
- upertino ga sl liabiliti ,judg...ems,Costs and expenses which PERMIT ISSUANCE 10.00 0 .CONST.TAX
Amy in ny, a accrue guind'said City in consequence of the
\ •anti oft Front' MECH.CONT. LIC.NO. MECH.
TOTAL /S_ TOTAL
Signature of Appli [ onl actor Dale
OFFICE COPY