15337 Af.PLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
` BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
1 r BUILDING APPLICATION & PERMIT q � �j
♦' ADDRESS I 1
-- - - BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
e
OWNERS ({�- OJ IJyq'y ,y PLAN CHECK VALIDATION
NAME 41' I OTV. ELECTRIC PERMIT FEE
PIFORE
a NAMECONTRACTORS Qy�J'j
NPME j� � CS3' I \LW� OUTLETS-SWITCHES-RECEP 10.00/1.00
ledE� 1 IC.NO, LIGHTING FIXTURES 10.00/1.00
CONTRAc*oR's APPLIANCES RESIDENTIAL 4.00
CONTRAS
��y}� PHorvE PANELS " 10,00 r
DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE 'P.C:NO,
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC,NO. SIGNS TRANS. 3.00
AARCH.OR
DDRESS ENG SPECIAL CIRCUIT 5.66 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 - UD
APPLICANTS - 'L_-
AODREss - MOTORS 'SEE FEE SCH. Q �O.DI I&,
149 S LL)Vt4 SERVICE CHANGE 20.00 eek 4" '
oo LICENSED CON TRACT ORS DECLARATIONgv
v u I herebyaffirm that 1 am licensed under provisions of Chapter 9 C-L&-e da L _, _CUPe-ISSUANCE DATE
w Q m (commencing with Section 7000)of Division 3 of the Business---- BLDG. ELECT. PLG. MECH.
F w z Professions Co II license is in full for gyn c
z o w- Date as 38 Lic.Nwnb T
O z H � Date Contractor _
r '-
aBUILDIRMATIO IT
¢ 0 w a OWNER-BUILDER DECLARATION
out.' MIST.- REFER TO ORD INFORMATION
S:
u m I hereby collo that 1 am exempt from the Contractor's License U VALUATION S/FT.
F u o a Law for the(allowing reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires permit to construct,aIle" '1 Q �L�..-i] -
QO improve,deiimlish,or repair any strcture,prior to its issuance,also ELEC.CONTR. LIC.NO' ELEC. �. cX V 0 `�
D rc requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
u w m u he is licensed pursuant to the provisions of the Contractor's License
rzi
Law(Chapter 9(conu..cremg with Section 7001 Division 3of1he SLl�iAl �x/G- d0'
a Business and,Profcs,ions Code)or that he is exempt therefrom andDTV. PLUMBING PERMIT FEE
r is the basis for the alleged exemption.Any violation of Section 703 1.5 1 STORIES- TYPE CONSTR.
n -; m by any applicant for a permit subjects the applicant to a civil penalty 001 5
DRAIN&VENT-WATER IEA. .
of not more than five hundred dollars($500).): ALTER-
❑ I,as owner of the property,or Ry employers 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 for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 5.00
Code The 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 5.00 SO,FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
.cutsare not intended oroffered for sale.If,however,the building GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or 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 hu did nor build or In).
prove for purpose of sale.). . INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB ' one.
- - - " ❑ 1,as owner of the property,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:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who iLAWN SPRINKLERS-OVER 5(EA.) 1.00 -
contracts for such projects with r cnntmclons)licensed pursuant In
ale ContractoLicense Law. SEWER-SAN ITARY-STO RM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I h am exempt Ruder Sec .B.BP.C.for this WATER HEATER W/VENT 6.00
lealm
Owner Date WATER SYSTEM - 5.00 ACC.DATE ACC.FILE NO.
WORK ERYCOMPENSATION DECLARATION WATER TREATING EQUIP. 5,00
I hereby affirm that I have a certificate of consent to self-insure' ZONING - ENG.SITE NO.
or a certificate of Workers Compensation Insurance,ora certified
copy thereof(Sec,3800,Lab.C.). _ �� o
Policy er Company -1i -
Q ❑ Cetlifiedcopyishe�rie�b�yyf.,r iilshedd. ,FIRE SPRINK ENERGYT24
Z i u�y.y,y p Applicvut MIST.- REFER TO ORD, v ❑ N❑ v ❑ IN
N CERTI FICA'I E OF:EXESIPI'ION PROM WORKERS' PERMIT ISSUANCE 10.00 Q FLOOD ZONE A.L.U.C.
LU > COMPENSATIONINSURANCE PLG.CONTR. LIC.NO. PLG. O (tU Y❑ N❑ v❑. NEI1 0 (This section need not be completed if the permit is for one TOTAL
Z) Z Into cd dollars l$1001 ser less.)
U O I cur - 't in rhe performance ul'the work for which this per' QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I s employ any Perron in any nwnner so as'tn
U become sublecl to the Wor ompensa tion Laws of California. D Sa
W Daze Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NO"1'ICE TO APPLICANT If,alter maks 'z Cc,rtificate of Iix- -
♦- Z_ innown,you should become subject to the wmize ompeneation APPLIANCE 5.00 PLAN CHECK �S/�a- -
provisions of the Labor Codc, you must forthwith c ly with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000GF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10.060C.F.M.) 6.00 SEISMIC FEE-
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the perwrmance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ,C). 1��CIH�-
Lender's Name HEATI NG 100,000 B.T.U.)9.50
Lenders Address ELECTRIC 1 _
® I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 1
information is correct.I agree to comply with all eity'and county PLUMBING D
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL Ste"
abovuanentioned property for inspection purposes.
-- (We) agree to save, in and keep harmless the City ofMIST. 2 �y(-$ 10.00 EFER TO ORD:
upertino against liabilities,judgmems, costs and expenses which 11 rti- CONST.TAX
ay in any way accrue against said City in consequence of the PERMIT ISSUANC
ranting OPtlLI it ( MECH.CONT. LIC.NO. MECH. -_
/n1^^1{•, �1 11 L _[/y TOTAL TOTAL
Signature pplicunt/Contractor Date
OFFICE COPY