14789 (5) kAPPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
'I- PERMITNUMBER
FJtTl
OING PROJECT I DENTIFICATI ON APPLICATION & PERMITqAgO�
II '4} 1100'�-9S" S - " C� BUILQING - ECECTRICAL"' PLUMBING-MECHANICAL'�pB' PLAN CHECK VALIDATION
CITY. .ELECTRICPERMIT -FEED '' / iPHONE .. • 4 .,'s OUTLETS-SWITCHES RECEP 10.00/1.00
' J PZ✓M (� nuc.NO. 7.$�� J LIGHTING FIXTURES 10:00/1.00 ' '
ro TRACTOR'S - APPLIANCES;RESIDENTIAL* 4.00'
ADDRESS '
-I-Qq/ eA/ PRONE2 �� PANELS ' - 10.00 ' DATE OF APPLICATION
1 ORNo I Ec - • 1 ' - PLAN CHECK FEE P.C.N0.
oR, PANELS (OVER 200 AMP) - 20.00
ENGINEER _ I uc.No. SIGNS TRANSI 3.00 '
ADDRESS ENG,•I' SPECIAL CIRCUIT 5100 - PERMIT VALIDATION-
. d '•' ` ZIP'^s. EMP.METER'OR POLE INS: ' .20.00
APPLICANTS - MOTORS' SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
0 0 LICENSED CON'IRACI ORS DECLARATION •� I'
SE u u 1 herehy affirm Ihet I an,licensed under provisions of Chapter 9 .ISSUANCE DATE
wz w - (commencing with Section 7000)of Division 3 of the Business and
Q'y - BLDG. ELECT, .PLG. MECH.
H Z Professions Codend Ivy h( Ilse is in full force and effect. ❑ o'
'Q C H W License Class _1139 case
Lie Number
• Dale Contractor
BUILDING PERMIT
0 WM < .-OWNI:R-BUILDERDCCI.ARA'I'ION - INFORMATION
X13,c w 'I hereby affirm that I'am exempt frons the Contractor's License MISC:- , REFER TO ORD - VA won ON
u O¢ Law for tike following reason.(Sec:7031,5;Businessand Professions- S/FT.
PERMIT ISSUANCE - . 10.00
. Code:Any my or county which requiresa permit to consln,el,alter
QSe ¢ 0 improve,'demolishi or repair any structure,print to its issuance,also ELEC.CONTE. LIG NO. ELEC.
ca
r_ wO R requires the applicant for,such permit to file a signed statement that - ,TOTAL PER MIT TO
m he Is licensed pursuant la the provisions'of the Cmueaetnr's Liccme -
i Law(Chapter 9(commencingwilh Section 7000)of Division 3 of the l-/
- ��17✓
L z Q' Business and Professions Code)or that he is exempt therefrom;HE OTY. PLUMBING PERMIT FEE
ricf S Othe basis forlhealle duxem tl n.AnY vtolationof Slelion 7031.5 STORIES TYPE CONSTR.
Ho be P n
a ;m by any applicant for a perm it subjects lhe.pplicanumac'i,ilpenally ALTER-DRAIN&VENT-WATER (EA.) 5.00 '
•'f of not more tion five hundred dollms(S500).). - -
'❑ 1,as'owner of the'prupurty,or Illy Cmployccs with Wages,IS BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
` their sole emnlft2al.timh,will no the work,and the slmctum is not
• intended or offered for sale (Sec. 7044, Business and 11fm'cssions DRAINSLFLOOR,'ROOF,AREA,GOND. 5.00 ,
i- Code:The Contm,tor's License Law II.S not apply la an ownerol
property Who builds or iTTIPHAVeS thereon,and who(IOCS SUC11 work FIXTURES-PER TRAPmf or , 5.00 SD.FT.FLOOR AREA ,TOTAL ACFEAGE
hiselthraugl hi wn molly s I r via d that improves - - ,
. menta are not intended or offr far s'I .If,however,thebuilding GAS-EA.SYSTEM-l1NC.40UTLETS '6.00
O or improvement Is sold within one year of completion,g Ieon, the-owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will hllve the burden of proving that he did not build or fill.
• prove for purpose of Sala.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB _ Other
❑ Las owner of the property,am exclusively contracting with El El - El ❑
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 non apply -- - - ,
to-an owner of property who builds or improves IIH,H.m.and who LAWN SPRINKLERS-OVER'5(EA.) 1.00
contracts for such projects with a contactor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10:00 M
the Contractor's License Law. 'TRACT NO. PARCEL NO. _
s ❑ 1 am exempt under.Sec.-.B.&P.C.tsar OUR
reason WATER HEATER W/VENT6.00
Owner - Uwe WATER SYSTEM' T ', 5.00 ACC.DATE ACQ FILE NO.
WORK ERS'COMPFNSATION DECLARATION WATER TREATING EQUIP. 5.00
I herchy affirm that 1 have a certificate of consent U+sclbinsure.' ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof fSc 800,Lah.CJ.
Policy No. Crnnpary
O ❑ Certified yishereby to Isf d.
Z
- FIRE SPR INK" ENERGY T-24
Z ❑ 'Certifi copy is fled iI the city inspection Aivision. MISC- REFER TO ORD. .
O . Applicant - Y❑ N❑ Y ❑ N❑
F tin - ` PERMIT ISSUANCE- - 10.00
. ,.�%- CRR JCAT OP Iixbmi TION I' WORKIiRS' O� FLOOD ZONE A.LU.C.
.W.� COMPENSATION INSU ANC
PLG.CONTR. LIC.NO. PLG. /
O• (This section need not be completed if the permit is for One TOTAL Y❑ N❑ Y E] N
hu ❑
D Z ndred dollars 15100)or IeM ,
U O I certify that in the performance of the work for which Ihix per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL I mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of Califonlia. - -
s'. 0 ED Dam Applicant BUILDING "•
)m m of I:x
NOTICE 1'O'APPLICANT': If,after..laking this Certificate - ALTER OR ADD TO MECH. 5.00
'•F 2 emption,you should become Subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK ,.
provisions of the Labor Code,,,you must forthwith comply with - FEE
C.1 such provisions or this permit shall be dcenhed revoked. AIR HANDLING UNIT(TO 10=CF.M.). 4.00
_
CONSTRUCTION LENDING AGENCY - AIR HANDLING UNIT(OVER 10=C.FM.) 6.00 SEISMIC FEE
1 hereby affirm that tlicre is a construction lending agency to, EXHAUST HOOD (WITH DUCT) 5.00 - -
the performance of the work lar Which this permit i,issued(Sec. -. 'MICROFILM
3097;Cie.C.). HEATING UNIT(TO 100,000 B,T.U.) 8.00 -
Lender's Name HEATI NO UNIT 100,000 B.T.U.)9.50 ';< -
Lender'sAddress' - ELECTRIC
I certify that I Inve read this Ipplh Illi n and stat that the.hove VENTILATION FAN (SINGLE) - 4.00
a information is correct. I erg 'e t mply will all itymail..only PLUMBING I✓J
`
ordirances,wid state laws relating to building eondru Ilan, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 -
hereby authoncer presenlath s 1 th city to enter upon 'h° BOI LER-COMP(Over 100,000 BTU)SEE FEE SCH.`. MECHANICAL.
above.-mentioned properly for Inspection liurpuses.
(W.),a' Cl. save; hide pity and kcep harmless the City of MISC:L REFER TO ORD." +
upertino gaihist liabilitiu I dgnmits, crista lu..._,vnsas which' PERMIT ISSUANCE' 10.00 -CONST.,TAX
s, mnyj' y way 'scene agt hsi sedi City In consequence of the .- "
G4
of this permit MECH.CONT. ' 'j• LIC.NO. MECHt &fl
• FF-6- - TOTAL i TOTAL
Sign lure o pplicant Contac r
F,; 0
FFICE COPY