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17515:i 'APPLICANT TO FILL IN INFORMATION WITHIN RED LINES' -USE RAL POINT PEN ONLY BUILDING PROJECT 1 DENTI FICATION- 'APPLICATION&PERMIT BUILDING -ELECTRICAL- PLUMBING -MECHANICAL PERMIT NUMBER - ,q k ��q I I J BUILDING N • /�NATLip OWNER'$ - - NAME pOrj - QTY. ELECTRIC PERMIT FEE PLAN CHECK.VALIDATION - - ff�TV` PHONE 'I . DATE OF APPLICATION CONTRACTOR'S- NAmE' ��a����1 1.a ,eJIhA -n60t1 ic.No.. 2 c OUTLETS -SWITCHES -RECEP -10.00/.1.00 LIGHTING FIXTURES ' • 10.00/1.00 CONTRACTOR'S AOOREss )y- fj�OP1 'Q•r / ' :YI'L, PHONE �jjO(• PPLIANCES- RESIDENTIAL 4.00- PANELS „10.00 ARCHITECT , OR ENGINEER _ - 'LIC. NO.' PANELS (OVER 200 AMP) 20,00 - PLAN CHECK FEE - P.C. Na. ' SIGNS TRANS. - 3.00 ARCH. OR ENG. ADORESS SPECIALCIRCUIT 5.00 PERMIT VALIDATION FAU0 EMP. METER OR POLE INS: .20.00 ZIP _ (1 IQ�rI 71 •i 11 �� ADDRE-ICSS _ ADDRESS 'wL i`:• � � JABS MOTORS SEE FEE SCH. SERVICE CHANGE ..20.00. LICENSED CONTRACTORS DECLARATION I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section 7000) Of Division 3 ofthe Business and PrOfea9lnns CO C a0d (Cense IS ln'fnll Cn fCe an eyySyL License Claps Lic Kumbcrb7i2�� -'^''�"'^' t I . ISSUANCE DATE BLO G.- ELECT. PLG. MECH. E - ❑.1' ❑ ' ., r��• '. ' ' Date !///'r ConUacmr � •' I� OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Sec. 7031.5, Businessand Professions Code A, or county permit construct, ,also any -'' ' ' - BUILDING PERMIT INFORMATION MISC. - REFER TO ORD •- PERMIT ISSUANCE10.00 VALUATION - $/FT. ELEC. CONTR. LIC. NO. ELEC. TOTAL demol improve, he applicant repair any structure, prior to its issuance, also it structure prior to heis les the applicant for such permit ns file a signed statement that he is licensed pursuant to the provisions of Contractor's License PERMIT TO Section 00 the Laww(Chand Code) _ r Professions or Business and Professions empt or that he is exempt therefrom and is exempt therefrom and the basis for the alleged exemption. Any violation o toarion malty by any ore tan ha fora unduesubjecrs the $500).licanitoacivil penalty of not more than five (my QTY. PLUMBING PERMIT FEE STORIES TYPE CONSTR. - ALTER -DRAIN -WATER (EA.) 5.00 em): ❑ e as owner at the property, or my employees with wages as he property, o their sole compensation, will do the work, and the structure is not 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 does not apply to an owner of DRAINS -FLOOR, ROOF, AREA ,CON D. 5.00 FIXTURES - PER TRAP �L • . 5.00 - GAS - EA, SYSTEM + 1 1 NC. 4 OUTLETS 6,00 - property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improve- ments are not intended or offered for sale. If, however, the building 50. FL FLOOR AREA TOTAL ACREAGE - br improvement is sold within one year of completion, the owner - builder will have the burden of proving that he did not build or am- prove for purpose of sale.). ❑ 1, as owner of the property, am exclusively contracting with 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 contractor(s) licensed pursuant to the Contractors License Law. ❑ lam exempt under Sec. ,B:&P.C. I'nr this reason GAS - EA. SYSTEM - OVER 4 (EA.)" 2.00 - BUILDING USE. RES' IND CON PB Other 1:1 13 El' ❑ 11licensed INDUSTRIAL WASTE INTER. 30.00 - '- ' I LAWN SPRINKLERS- 1 INC 5 VB.'; '''6.00 . ASSESSORS PARC E D NO. .. LAWN SPRINKLERS - OVER 5 (EA.)1.00 SEWER -SANITARY -STORM EA: 200ft/10.00 TRACT NO --WCC.-DATE, ,PARCEL NO. FACC. WATER HEATER W/VENT 6.00 Owner Dace - WATER SYSTEM 5.00 - FILE NO, WATER TREATING EQUIP. )., 5.00 WO RKFRS'COMPENSATION DECLARATION I hereby affirm that 1 have o certificate oCconsent to self -insure, - ZONING ENG. SITE NO. - or a certificate of Workers' Compensation Insurance, or a certified- copy thereof (Sec. 3800, Lab.C.). - - Policy No. Company i - '❑ Certified copy is hereby furnished Certified w IE Bled wit he city Inspection division. Applicant µr FIRE SPRINK Y❑ N❑ ENERGY T -Y4 Y❑ ' NQ MISC.- REFER TO ORD. CERTIFICATE.OF' EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: ' (This section need not be completed if the permit Is for one PERMIT ISSUANCE 10.00 FLOOD ZONE .'" Y ❑` N❑ A.L.U.C.' - Y ❑ N❑ PLG. CONTR. u0. NO. .. PLG. - TOTAL hundred dollars IS 100) or less.) - . I certify that in the performance of the work for which this per- mit is issued, I shall not employ any person in any manner so as to OTY. MECHANICAL PERMIT FEE FEE SUMMARY become subject to the Workers' Compensation Laws of California. - Date Applicant ALTER OR ADDTO MECH: '„ '• 500 1.. . BUILDING . NOTICE TO APPLICANT: If, after making this Certificate of Ex- APPLIANCE 5.00 - l •Z, AIR HANDLING UNIT (TO 10A000.F.M.). 4.00 ry PLAN CHECK FEE ' emption, 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. AIR HANDLING UNIT (OVER 10p00CF.M.) 6.00 SEISMIC FEE CONSTRUCTION LENDING AGENCY EXHAUST HOOD (WITH DUCT) '- • ' 5.00 HEATING UNIT (TO 100,000 B.T.U.) 18.00 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Co.CJ.' MICROFILM ^ Lendch Name Lender's Address HEATING UNIT (OVER 100,000 B.T.U.) 9.50 }, ELECTRIC',: ' I certify that I have read this application and state that the above information is correct. I agree to comply with all city and countyPLUMBING ordinances and state laws relating to building construction, and hereby authorize representatives of this City to enter upon the above-mentioned property for inspection purposes. VENTILATION FAN (SINGLE) '' " 4.00 BOILER- COMP (3 H.P. or'100,000 B.T.U.)• 6.00 - - BOILER -COMP (Over 100,000 BTU) SEE'FEE SCH. _ MECHANICAL ' (We) agree to save; indemnify, and keep harmless the City of upertino against liabilities, judgments, costs-anJ expenses which an in any way accrue against said City in consequence of the ranting of this permit. MISC. -- - REFER TO'ORD. - PERMIT ISSUANCE a . ' , 10.00 CONST. TAX ` MECH. CONT. LIC. NO. MECH.• Signa ure-oot f Applicant/Cont tor- - -Date . TOTAL • - TOTAL OFFICE COPY.