09569APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BU LDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING — ELECTRICAL— PLUMBING —MECHANICAL
PERMIT NUMBER
09569
BNLLDING
ADDRESS
10191 Yoshino Place
OWNER'S
NAME -
Eileen Crosno ,HONE 257-1474
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
(CONTRACTOR'S
NAME
Atlas Heating Lie No. 65266
JOUTLETS -SWITCHES -RECEP 10.00/1.00
ILIGHTING FIXTURES 10.00/1.00
CONTRACTOR S _
33 Commercial St. PHDNE739-0516
APPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
ARCRITECTunnyv a
OR
ENGINEER
LIC. No.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH.
Cs ENG.
ADDRESZIP
SPECIAL CIRCUIT 5,00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
AS
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Divisio�nt'3 of the aB[usiness and
License C sy ._— Lic. Number+^U�Y-JL1.J L7
PfOf0i61011 ]'t.'011 1 y IIl:C11 Li 191x1 toll [l C1 %ating
Date / Contractor
ISSUANCE ATE
BLDG. ELECT. PLG. MECH.
❑ ❑ ❑
'
OWNER&BUILDER DECLARATION
I hereby affirm ing r I nm exempt from the Contractor's License
Law fortheity owingreason.chrec resa ermB.sit Dl Bud Professions
Code: Any city or county which requirese Iwrmit to construct, alter,
BUILDING PERMIT
INFORMATION
MISC.— REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
$/FT.
ELEC. CONTR. LIC. NO. ELEC.
TOTAL
requires, demolish, or repair any structure, prior to its issuance, also
he islicllled Pena tt the permit to file oftaSignedactor''s Li that
pursuant to the provisions of the Contractor's License
he is (Chapter or Section 00) the
Law (Chard
PERMIT TO
,s
/ taz
Professions de) is exempt
bais and Professions Code) or that he isexempt therefrom and
DTV. PLUMBING PERMIT FEE
'
the
the basis for the alleged exemption. Any violation oto action 7 nalty
by of ramlicanl fore undresubjects ollar,$500).liwnt d+ucivil Penalty
of not marc than five hundred dollars (SSOOIJ:
STORIES
RI
TYPE CONSTR.
ALTER-DRAIN-WATER(EA.)5.00
❑ 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work. and the structure is not
BACK F LOW PROTECT. DEVICE 4,00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: 'The Contractor's License Law does not apply to an owner of
FIXTURES - PER TRAP 5.00
GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
SO. FT. FLOORAREA
TOTAL ACREAGE
property who builds or improves thereon, and who doe] such work
himself or through hie own employees, provided that Such inquave-
mentsarcnotiatendedoroffered for sale. If, however, the building
or inlprove`ment is sold within one, year of completion, the owner-
builder will have the burden of proving that he did not build or im-
grove of ra
1, as ole.).
❑ 1, as ownernee of the property, am exclusively contracting with
- . -..
GAS EASYSTEM OVER 4 (EA) 200
BUILDING USE
RES IND CON PB Other
0 Cl 1:1 0 El
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code', The Contractor's License Law does not apply
to an owner of property who builds or improves thereon. and who
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS • OVER 5 (EA.) - 1.00
ASSESSORS PARCEL NO.
contracts for such projects with a contractor(s) licensed pursuant to
the Contractor's License Law,
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ I am exempt under Sec.—, BAP.C. for this
reason
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC.OATE
ACC. FILE NO,
WATER TREATING EQUIP. 5.00
WORKf:RS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure,
or a certificate Workers'Compensatttii//ioonnn Insumn",]or a certified
ZONING
ENG, SITE NO.
�L/yoff
❑ (:edified copy is hereby furnished.
Cedifiml cov iled.Qw/4taran ivision.
1[
FIRE SPHINK
Y [] N ❑
ENERGY T-24
Y [] N�
MISC. - REFER TO ORD.Applicant
CE111IFICATE 017 EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A. L. U.C.
COMPENSATION INSURANCE
(This section need not he completed if the permit is for one
PLG. CONTR. LIC. NO.
PLG,
TOTAL
Y ❑ IN
Y ❑ N❑
hundred dollars ($100) or IessJ
1 certify that in the performance of the work for which this per-
mit is issued 1 shall not employ any person in any mmnner so as to
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers Compensation Laws of California.
Date ApplicantALTER
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
OR ADD TO MECH.
APPLIANCE00
■
AIR HANDLING UNIT (TO 10)0000. . Aa
PLAN CHECK
FEE
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply will
such provisions or this permit shall be deemed revoked,
AIR HANDLING UNIT(OVER 70,000 C.F.M.) 0
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby afthat there is a construction lending agency for
firm
the performance of the work for which this permit is issued (Sec.
3097, CDC.).
EXHAUST HOOD (WITH DUCT)
MICROFILM
HEATING UNIT (TO 100,000B.T.U.) 8.00
Lender's Name
Lender's Address
HEATING UNIT (OVER 100,000 B.T.U.)9.501
ELECTRIC
I certify that 1 have read this application and stale that the above
VENTILATION FAN (SINGLE) 4.00
is correct. I agree to comply with all city and county
jounces and state laws relating to building cons[RlClion, and
PLUMBING
BOILER•COMPI3H,P.Of100,0008.T.U.1 6.00 6.QQeby
(Over 100,000BTUISE F H.
MECHANICALve-mentioned
uuthorixe representatives of this city to enter upon theBOILER-COMP
property far inspection purposes.We)
MISC. - REF RD.
agree to save, indemnify and keep harmless the City of
[formation
ertino against liabilities, judgments, costs and expenses which
in any way accrue against mid City in consequence of the
of this permit.
atureo plica t/ ontrxc Date
PERMIT ISS _zzy
10.00ting
CONST. TAX
MECH. CONT. ECH.PZ
TALTOTAL
Atlas Heatir� 465266 $16.00
OFFICE COPY -