14417 (6) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON - - PERMIT NUMBER
eGILOINc "L• APPLICATION &.PERMIT 14417
Ao EEss '
�Q _G' A � N ✓�L6 BUILDING - ELECTRICAL-PLUMBING-MECHANICAL ..
-(F'0, 0 NER'S �l PLAN CHECK VALIDATION
i QTY. ELECTRIC PERMIT FEE
to /�Y� (r �i ✓'PHONE 7 `O IS7 771 �Q
NA"ERacTOR's y�( UTLETS-SWITCHES-RECEP 10.00/1.00
•� N Llc.No. 'J 3 LIGHTING FIXTURES 10.00/1.00
ro"rRAcrDR'S ! APPLIANCES-RESIDENTIAL 4.00
// �� (,�v PHONE 3� 'a PANELS 10.00 DATE OF APPLICATION
ARCHITECT /w' PLAN CHECK FEE P.C.NO.
OR L.R�. rirT.a;sOG' PANELS (OVER,200 AMPI 20.00
ENGINEER //��//J� �/
LI NO,'OZ .50 SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADOR ss �J'.G pp SPECIAL CIRCUIT 5.00
Q Looe vAJ Alii. z11/9S TEMP.METER OR POLE INS.' 20.00 PA
ADDRESS MOTORS SEE FEE SCH. !v
SERVICE CHANGE 20.00 a S
GFz0 /OO LICIiNSEU CONTRACTORS DECLARATION
a u 1 hereby affirm that I am licensed under provisions of Chapter 9 IIIDATE
(cYmmrencing with Section 7000)of Division 3 of the Business and
"'
rfi a m PLG.. MECH.
r t Professions code, t y license is in full for cedyfXt
A m- / License Class Lin.Number -
o '_'s+L Date_�/L..Q Contractor
M M 4
rc a owlvERdluaueR DECLARATION BUILDING PERMIT
o a INFORMATION
E:
; LL H. I hereby affirm that I an exempt from the Contractor's License MISC.- REFER TO ORD
e_ O¢ Law for the following reason.(Sec.7031.5,Business and Professions VALUATION
H - N g PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter, DLA ,W{
0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. C.NO. ELEC. Com/ OC/ V
T. O LL requires the applicant for such permit to file a signed statement that TOTAL
he Is licensed pursuant to the provisions of the Contractor's License PERMIT TO
F z a
Law(Chapter9(commencing with Section 7000)of Division 3 ofthe �M�Q
4 O Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
M r-$ the basis for the alleged exemption.Any violation of Section 7031.$ i STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant too civil penally
of not more than five hundred dollars(SS00).): ALTER-DRAIN&VENT-WATER (EA.)' 5.00
❑ I,as owner of the property,or my employees with wages:s BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sale compensation,will do the work,and the structure is not
intended or offered for sale (See. 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 build,or Improves lhereo ,and who does such work FIXTURES,PER TRAP 5.00 SO.IT.FLOOR AREA TO TAC ACREAGE
himself or through his own employees,provided that such Improve
Dents are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of moving that tic did not build or im- - BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ I,as owner of the properly,am exclusively 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: fire Contractor's License Law does not 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 conlractorls)licensed pursuant to SEWER-SANITARY-STORM EA.200ft
the Contractor's License Law. /10.00 TRACT NO. PARCEL NO.
❑ [am exempt under Sec. ,L&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner _ Date WATER SYSTEM 5.00 ACC:DATE ACC.FILE N0.
WORKERS'COMPENSA'I'ION DECLARA'T'ION WATER TREATING EQUIP, 5.00
I herohy Whun that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,ora certified ZONING ENG,SITE NO,
copy thereof(See.3800•Lab.0).�(-/
Policy No. m
Copany ui •O+i,/w/me
O ❑ Certified copy is hereby furnishod. FIRE SPRINK ENERGYT-24 '
Cerlifle o i, file wash the t$ e'Iion division. !MISC.- REFER TO ORD.
Z z ,_�Xa" 7 V [] N� V [] NE]
pf/ Kpphcan!
W/ CERTIFICATE OF EXF.MP'I'ION F-ROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W 5 COMITNSATION INSURANCE PLG.CONTE. LIC.NO. PLGEL .
Z( This section need not be completed if the permit is for one TOTAL V N V F] N
hundred dollars(S 100)or lines)
C) El
O I certify,that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner so us to
o-U become subject to the Workers'Compensation Laws of California.
ED Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING 33 J�
>_ So NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z emplion,you should become subject to the Workerc'Contpereation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must Rrrthwith comply with FEE
[) such provisions or this permit shall he deemed revoked. - AIR HANDLING UNIT(TO 10,000QF.M.) 4.00 '
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MCC.F.M.) 6.00 SEISMIC FEE � ?'
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(Sec. MICROFILM
3097,Cie.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Nome HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that,have read this application and state etre,the above VENTILATION FAN ISINGLE) 4.00
information is correct. 1 agree to comply will]all city and county BOILER- H.P.Or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and _ _ -
hereby of this purposes.
thori<c representatives ths city to enter upon the
above-mentioned property forinspectionBOILER-COMP (Over 100,000 BTU)SEEFEESCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
upertino against liabilities,judgments, costs and expenses which - CONST.TAX
may y way awruc ogtiinst said City in consequence of the PERMIT ISSUANCE 10.00
r mgo [his pe I. MECH.CONT. LIC.NO. MECH.
TOTAL I TOTAL 3
are of Applicant/Comractor Date
OFFICE COPY