18846APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING -ELECTRICAL -PLUMBING -MECHANICAL
.PERMIT NUMBER
1 /8 846
I �J
BUILDING
ADDRESS 1034-1 /`�kL l' Q L,'H'1''�
y�y
OWNER'S
NAME AeVII "VIJ ct4d
r
P ONE,y
QTYELECTRIC PERMIT FEE
PuoanoN
-5(9,45
CONTRACTORS �
NAM
Ge%W�J`p
L�"I`s�
UTLETS-SWITCHES -RECEP 10.00/1.00O
LIGHTING FIXTURES 10.00/1.00
^Il
LIC, NO
DATE OF APPLICATION
S
y
2 caw/imylov
PPLIANCES- RESIDENTIAL 4.00CONTRACTOR
PANELS 10.00
T
CfveV 1 {A 950o
PANELS (OVER 200 AMP) -20.00
PLAN CHECK FEE P.C. NO.
ENGINEER
WPIDYuc. ND.' �Of
SIGNS TRANS. 3.00
A REAS NG'
SPECIALCIRCUIT S.QQ
PERMIT VALIDATION
0 C C zm
EMP. METER OR POLE INS. 20.00
noo Ipess s f�P/ tAS �'� sjj-b� f-
MOTORS SEE FEE SCH.Per
CHANGE 20.00
10341 j,SERVICE
.,_Ivan,•� 'L�
ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I ani licensed under provisions of Chapter 9
(commencing with Section 7000) of Division i of the Business and
Professions Cole, ei t my license is in full force ani � ll
DLicense Class Con Number -6
Dale Contractor-
Wil a[ I on, examDER t fromDECLRATION
I hereby affirm that f am exempt from the iContractor'sssdPro License
Lawf Any city or countywhihng reason. requireso permit toond Professions
structur e permit t toconstruct, issuanc, alsolter,
county it any
impro e. dem y demolish,
improve. Demolish, or repair any stmt toe, prior to its issuance, also
requires the applicant for such permit to file i signet actor's i that
he is licensed 9 (comm to the provisions of 00 Contractor's License
Law (Chaplet r(commencingwith Section is exeofttherer3of the
Business and Professions Code) or Thal he is exempt action 70 and
(Ise basis for the alleged exemption. Any violation of Sec Nil malty
by any applicant ford permit subjects tire applicant Macivil penalty
of not more Than flue hundred dollars 15500).1:
❑ I, as owner of the properly, or my employees with Weas
their sole compensation, will do the work, and the structure is not
!I
BUILDING PERMIT
INFORMATION
MISC. - REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
tri
) _
S/FT.
ELEC. CONTR. LIC. NO.
ELEC. t
TOTAL
PERMIT TO
AI C'I ii L'
DTV. PLUMBING PERMIT FEE
ALTER -DRAIN -WATER IEA.) 5.00
STORIES
TYPE CONSTR.
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon, and who does such work
himself or through his own employees, provided [hat such improve.
mems are not intended or offered for sale. If. however, Ino buildingGAS-EA.
DRAINS -FLOOR, ROOF, AREA, GOND. 5.00
FIXTURES - PE Tfl AP 5.00 Ot(Yf
SV IINC.4O TLETS 6.00 L
SD. FT. FLOOR AREA
I /til I
TOTAL ACREAGE
or improvement is sold within one year of completion, the owne
builder will have the burden of proving that he did not build or ins
prove for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with
GAS - EA. S - OVER 4 A.) 2.00
BUILDING USE
RES IND CON PB Orion,
INDUSTR L 4ASTr INTAI. 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
contracts for such projects with a contracloRs) licensed pursuant to
the Contractor's License Law.
❑ I am exempt under Sec. ,B.&I'.C. for Ibis
reason
LAWN INKLERS- 1 C 5 V.B. 6.00
L WN SITINKLERS - OVER 5 IEA 1.00
ASSESSORS PARCEL NO.
S A T V-$ ORM EA. 20 t/ 0.00
TRACT NO.
PARCEL NO.
TER HEA V T
Owner Date
iV4rER VST .00
ACC. DATE
ACF FILE NO.
WORK ERS'COMPENSATION DECLARATION
ATER aT'ING EikUIP.5.00
Iti
I hereby affirm that I have a certificme of consent to scl6inaun..
ZONING
ENG. SITE NO.
' or a certificate of Workers' Compensation Insurance, or a certified
Copy thereof (Sec. 3800. Lxh.C.).
Policy No. Company
❑ Certified copy is hcmby fumished' -
❑ Certified ropy is Oled Will, the city inspeclian division.
Applicant-.-
i R PERT RD^'.,/
FIRE SPRINK
v N�
ENERGY T-24
Y N�
('I.RTIPIC'ATE01' EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
seclion meet not he completed if Il,c permit is far one
41OGIRMIT I$SU NCE. '1 \ 0
FLOOD ZONE
Y NE]
A.L.U.C.
Y NE]
PLG.CONTR. LIC. Q. P/. r
hundred dollars f E 1001 or less.)
I certify that in the performance of (he work for which (his per-
our is issued, I Shall not employ any person In any nlamicr So as to
become subject to [he Workers' Componsalion Laws of California.
Date Applicant
QTY. M AFI
I AL PE M
FEE
FEE SUMMARY
BUILDING
ALTER O A D O MECH. _
APPLIANC y5.00
AIR HANDLING UNIT (TO 10,o0O .i^"
NOTICE TO APPLICANT'. If, after making this Certificate of Ex-
eruption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
PLAN CHECK
FEE
'-
AIR HANDLING UNIT IOVER10J=C.F.M.)'b:w
SEISMICFEE
MICROFILM-'
CONSTRUCTIONLENDINGAGENCY
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (See.
3097, Civ.C.L
EXHAUST HOOD IWITH DUCT) 5.00 ac"
HEATING UNIT ITO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address
HEATING UNIT (OVER 100,000 B.T.U.I B.50
ELECTRIC
I certify that I have read this application and stale that the above
information is Correct. 1 agree to comply with all city and Cowity
ordinances and ,late laws relating to building construction, ant
hereby authorize repertyforlvesins of on city to enter upon the
shove -mentioned pmPerty for inspection purposes
VENTILATION FAN (SINGLE) 4.00
BOILER-COMPI3H. Ror-100,000B.T.U.) 6.00
PLUMBING
33tea
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
L (�
(We) agree to save, indemnify and keep harmless file City of
upertino against liabilities, judgments, costs ant expenses which
nay in any way accru agai nal said City in consequence f the
ranting of this per ' .
Signature of Apph'antjCortraclor Uatc
lin - REFER TO ORD.
PERMIT ISSUANCE .00
CONST. TAX
MECH. CONT. UC. NO.
MECH.
TOTAL �/�yy��
g(�(/
TOTAL
OFFICE COPY