18698 APPLICANT TO.FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUIIOING APPLICATION $( PERMIT '
ADDRESS
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 18698
'74V BUILDING ..
OWNER'S - - PLAN CHECK VALIDATION
"yyAMF�E y '1%R I/J .�rr�, QTY. ELECTRIC PERMIT FEE
Vl�Ir L'/ MmePRONE V013- .
CONTRACTOR'S
NE� '�.�G,�Gj- ' OUTLETS-SWITCHES-RECEP 10.00/1.00
LICIPINI Z AMS? LIC NO. bLb;J LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S 40**3G0 - APPLIANCES-RESIDENTIAL• 4.00
O C, TIE: PRONE ✓ PANELS 10.00
DATE OF APPLICATION
on CT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.ND ISIGNS TRANS. 3.00
ADDRESS E"G' SPECIAL CIRCUIT 5',00 PERMIT VALIDATION
zip EMP.METER OR POLE INS. 20.00
APPLICANTS
MOTORS - SEE FEE SCH.
FEES
A
SERVICE CHANGE 20.00
Woo LICENSED CONTRACTORS DECLARATION r `-"-" r, :
¢ v 1 hereb affirm that I am licensed undo revisions of Chapter 9 !
Q h (ennunenc ng with Section 7000)of Division 3 of the Business and
^ 'r - ISSUANCE DATE -
F D Z Professions Coll•r license is in fall 1,r��� BLDG. ELECT, PLG. MECH.
Z o m License a Lic.Number El �' El IV
O o, -O Date �e Contractor I{ '
< : 5 440
¢ ¢ w Q OWNER-BUILDER DECLARATION - BUILDING PERMIT
K:
;u , I hereby al'firn that I am exempt front lite Contractor's License MISC._ INFORMATION
Fgo'J Law for the following renron.(Sec.7031.5,Businessand l'rr(ess'ions PERMIT ISSUANCE 10.00 vnLunnoN $/fT.
m� Code:Any city or county which requiress permit to construct,alter,
QaQ2 improve, or repair any Structure,prior to its lssounCe,also ELEC.CONTR. LIC.NO. ELEC.
i E o ¢ requires the applicant for such permit to file a signed statement that _ TOTAL
w �'w he Is licensed pursuant to the provisions OI'[lie Contractor's License PERMIT TO
-•-rz > Lass(Chapter 9(commencingwith Sectimt7000)of Division3ofthu
M 1-
Q (fullness and Professions Code)or that he is exempt tlemfrom and QTY. PLUMBING PERMIT FEE
¢ Fom the basis for the alleged exemption.Any violation ofSeClion 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applieanuo a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).): -
0 1,as Owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR, ROOF,AREA,COND. 5.00 '
Cade:The Contr'actor'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 s0.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
nents are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00 '
at improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose ofsaleJ. INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer .
❑ I,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 Convector's License Law Anes not apply
to:in owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contrucims)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under,Sec. ,R&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM a 5.00 ACC.DATE ACC,FILE NO.
WORK ERS'COMITNSATION DECLARATION WATER TREATING EQUIP. 5.00
1 Hereby tfOrn that I have a certificate ofemisent 10 self-insure, -
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITENO.
'opy Ihcre 5�' -3 0Q 1pally ) 'F
Policy No. ,,many
O ❑ Certified cGy s erehy in is
I
z Z Certified FIRE SPRINK ENERGY T-24
p t tl t e9ton division. ❑ ❑ ❑
p plicae v MISC.- REFER TO OR y N v N
CC m CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00
-'FL' ]ZONE A.L.0 C. .
W > COMPIiNSA'I'ION INSURANCE PLG.CONTR. uC.No. PLG.
CL a Z (This section need not he completed it lite permit is for one TOTAL Y N Y [:3N❑
hundred dollars(S 100)or less.)
U O 1 certify that in the performance of the work for which this per OTY. MECHANICAL PERMIT FEE FEE SUMMARY
U. I- Hilt is issued, I shall not employ any person in any nwnnerso as to
O W beemaa subject to the Workers'Compensalion Laws,ECalilornia.
d Dec Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE,TO APPLICANT: If,after making this Certificate of lix-
f.. ? emption,you should become subject to lite Workers'Compensation APPLIANCE 5.00 PLAN CHECK .
provisions of the Labor Code, you must forthwith comply with FEE
(� such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 1000C.F.M.) 6.00 SEISMIC FEE
I 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,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00 dV
Leader's Addr HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address - ELECTRIC
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
dinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
covey enti orid roperty for ins inspection
this city es cora upon the BOI LER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned anlioned propene for inspection purposes.
(We) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
upertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 [� CONST.TAX
may in an way accrue again said Cit n
in consequence of the
Nanlir f i5 permit MECH.CONT. LIC.NO. MECH.
,I TOTAL
5 = TOTAL
Signature of ApplicantrContraaor ate �� �'(,7 �1 I ��
OFFICE COPY