13697 APPLICANT TO FILL [N INFORM? 410N WITHIN RED LINES — USE BALL POINT PEN ONLY
1 L I N PROJECT I DENTI FICATION PERMIT NUMBER
a,,,Lp,NG APPLICATION & PERMIT
AaORESS BUILDING—ELECTRICAL—PLUMBING—MECHANICAL 13697
6
s)'• PLAN CHECK VnuonnoN
FEE N ELECTRIC PRMIT
l0 irl PA� J �YJ l�:)fPNbNE f/� // .i
•- NAME YY- UTLETS-SWITCHES-RECEP 10.00/1.00 I
Lic NO. (LIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.001
ADDRESS
FHONE PANELS 10.00 DATE OF APPLICATION
ARCNRECT I (PANELS (OVER 200 AMP) 20.001 PLAN CHECK FEE A PC NO
On
ENGINEER
tic NO I SIGNS TRANS. 3.00
ARCH.OR ENG. _ SPECIAL CIRCUIT 5.00 PERMIT VALID TtON
ADDRESS
ZIP I (TEMP.METER OR POLE INS. 20.00
A PLICAsTS MOTORS SEE FEE SCH. ,V
SERVICE CHANGE 20.00f��'7
0 o 2i LICENSED CONTRACTORS DECLARATION
a v W 1 hereby affirm that I am licensed under provisions of Chapter 9 I ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG ELECT. PLG, MECH,
I:,N i Professions Code,and my license is in full force and effect. I I ❑ - 1 ❑ 1 ❑ ❑
as 0 w Liecase Class Lic,Number
2 w F w Dare Contractor
Q y I J 1 1 { .V°.BUILDING PERMIT^v'•�'"
_ w¢ OWNER-BUILDER DECLARATION Ct' ''d*u�Av
A. 0 v ° IM ISC,— REFER TO ORD • "^%' INFORMATION '�
A. I- 1 hereby affirm that 1 am exempt from the Contractor's License VALUATu6N` r SIFT.
is u 0 Fr Law for the following reason (Sec.7031.5,Businessand Professions FERMI: ISSUANCE 10.00 f
Code:Any city or county which requires a permit to construct,al ter, O
¢ ¢Q 0 improve,demolish,or repair any structure,prior to its AsuanCe,also ELEC.CDNTR. _IC NO. ELEC. A Q
m LL requires the applicant for such permit to file a signed statement that I TOTAL , PERMIT TO
A w he is licensed pursuant to the provisions of the Contractoi s License _
r2i
Law(Chapter 9(commencing with Section 7000)ofDivisi on3.(the �,ar.4ic,-r°+£ `a }'
< Business and Professions Code)or that he is exempt therefrom and ITY p t PLUMBING PERMIT '4r 4 4`E FEE
¢r o the basis for the alleged exemption,Any vmlation of Section 7031 S 1 t'at:N'"r It x* -P '1?.,PLUMBING P - ''3 kL�" b � - 5TO IES TYPE CONBTR 1
i;m by any more fore permit subjects the applicant to civil penalty ALTER-DRAIN -WATER(EA.I 5.00
of not mare than five hundred dollars(5500))
0 1,as owner of the property,or or employees 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 I IDRAINS-FLOOR,ROOF,AREA,COND. 5.001
Code The Contractors License Law does not apply to an owner of
property who builds or improves thereon,and who does such work I FIXTURES-PER TRAP 5.00 I SO.FT.FLOOR ARES TOTAL ACREAGE
himself or through his own employees,provided that such imprG, -
ments are not intended or offered for sale If,however,the building I GAS-EA.SYSTEM,1 INCA OUTLETS 6.001
or Improvement is sold within one year of completion,the Owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUtLDrtG USE
budder will have the burden of proving that he did not build or im-I RE5 IN CON Pe Diner
prove for purpose of sale) IINOUSTR IAL WASTE INTER. 30.00
❑ 1,as owner of the property,am exclusively contracting with I i ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V,B. 6.00 { ASSESSORS PARCEL N0, l
and Professions Code The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who I LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractons)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law I TRACT NO PARCELNO
mason l am ex�i^nil ec B SP.C.for (WATER HEATER W/VENT 6.00
�tOwner ! L (�� - Dat� WATER SYSTEM 5.00 I ACC DATE ACC.FILE NO,
WORKERS'COAIPENSATION DECLARATI I WATER TREATING EQUIP. 5.00 I
I hereby affirm that I have a certificate of consent to self-inslPe'I _ ZONING or a Certificate of Workers Compensation Insurance,or a certified _ ENG.SITE NO.
cop)there.((Sec.3800,LA.C.).an
Policy N.. Compy
0 ❑ Cevitiedeopysshembyfumnined Fl RESPRINK ENERGY 424
z Z ❑ Certified copy is filed with the city inspection division MISC,- REFER TO ORD. N
— Q Applicant y❑ N❑ v ❑ ❑
Y ti CERTIFICATE OF EXEMPTION FROM WORKERS' I PERMIT ISSUANCE 10.001
FLOOD ZONE AL U C
L > COMPENSATION INSURANCE IPLG.CONTR. LIC NO. (PLG.
1 O (This section need not be Completed J the permit is far one TOTAL v❑ N❑ v ❑ N❑
Z hundred dollars IS 100)or less) >_ __—
O 1 oeru(y,that m the performance of lire work for which this per- -0`i` _ FEE SUMMARY
F mu¢issued,!shop not employ any person m any manner so as to QTY,.<j- ,,,,I ..n p,,MECHANICAL,PERMIT _r FEE ___-
L become subject to Eire Workets'ComperMilu m Laws of Cat r.rnia I`'�"' -`,n- °,,:+` - - - - - -`--"—
W Date A plicam " I BUILDING
a p ( ALTER OR ADD TO MECH. k 5.00 o2O
to NOTICE TO APPLICANT. If,after making this Certificate of Ex. _
? empu.n,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply wdh FEE / J
SO ch provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MOGF.M.) 4,00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(C 10,000O.F.M.) 6A0 SEISMIC FEE
I hereby affirm that there is a construction lending agency for I EXHAUST HOOD (W1 DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Crv.C.). I HEATING UNIT(TO 100,000 B,T,U.I 8.00
Lender's Nam-
HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Addre= I ELECTRIC
i certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
.L 'nformauon Is correct I agree to comply with all city and county, PLUMBING
;P 7may dimmees and state laws relating to building e.strnCti.n, and
BOILER-COMP(3 H.P.Or 100,0008.T.U.) 6.00
-reby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTUI SEE FEESCH. MECHANICAL
bove-mentioned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of I MISC.- REFER TO ORD.
upertino against liabilities,judgments, costs and expenses which CONST.TAX
in an way acer against said City to consequence of the PERMIT ISSUANCE 10.00
antln �' r MECH CONT. UC NO. MECH
Urrt-� pP / TOTAL TOTAL' 3 a or hcan Contractor jYla e
OFFICE COPY — —