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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATIONPERMIT
- APPLICATION &PERMIT
BUILDING - ELECTRICAL- PLUMBING -MECHANICAL
NUMBER
I 17811
i
aiNG �-I- 13
aGranooR Ess
2059 CA�DF�-ISI Di= ��I2C1
OWNER '$
NAME y �rr,yf
PHONE 133 qw' `5
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
NON>ERAcrORs p� nye` _ i
a'Y7 N6' F-
UTLETB- SWITCHES -RECEP 10.00I1.00
LIGHTING FIXTURES 10.00/1.00
Llc,
.
-
_
DATE OF APPLICATION
CONTRACTORS
ADDRE �7^
! N PHONE
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
A.CHtTOCT ,
OR
ENGINEER EN
' I.E. NO.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH EOR ENG.
ZIP
5,00
PERMIT
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
AES
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACT ORS DECLARAT ION
1 hereby affirm that I am liccmed under provisions of CvplFc>161111i
(commencing with Section 7000) of D,vuion i of the Bus, an
Professions Code and my license non full form and effect
PAID
URUTIM
ISSUANCE DATE
BLDG.
ELECT.
PLG.
—sitYK
Licent Class Lie. Number
Date Contractor -
/ J -7 fry /-1 ( '1' 4 1"` J
l
BUILDING PERMIT
.INFORMATION
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Coss and P's License
Law for the following reason. (Sec 7031.5. Business tocnd Professions
,mprov0. demolish, of rapes any nnit structure prior to its aseance, also
e, also
C,nove, y city or rounty which mquitesaure Permit riot o is issuance,
o sConJ statement that
requires theapplicantfor such permit ns of
he is licensed punuam In the provision of the License
//J I
T i G-
M ISC- '. QpR�l R
''
PERMIT ISSUANCE 4&B0 IA)
VALUATION
Q 00
I L7 (JC_JQ
S/FT.
,
ELEC. CONTR. LIC. NO. -
ELEC. 51 iD �]
TOTAL
PERMIT TO
QTY. PLUMBING PERMIT FEE
1 1 Division
Lew (Chapterand ProaommenCode) or Section is exempt
Bluincss and Professions Code) or that he s exempt thcrtfrom and
Utheref o and
✓1'�
ES
STORIES
TYPE CONSTR.
the basis for -the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred doIN,,(f500)J:
(/— H
ALTER -DRAIN & VENT -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 FLOW 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
property who builds or improves thereon, and who des such work
himself or through his own employees, provided that such improve.
ments are not intended or offered for sale. If, however, the building
�.7J
FIXTURES -PER TRAP 5.00
SG. FT. FLOOR AREA
IDS7
TOTAL ACREAGE
jQ'�A/y�
4M
GAS - EA. SYSTEM- 1 INC. 4 OUTLETS 6.00
For Improvement is sold within ono year of completion, the owner-
builder will have the burden of proving that he did not build or im-
prove for purpose ofsale.).
the property', am exclusively contracting with
I, as owner of pe
- .
GAS EASYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
RES
^ESIND CON PB Omar
/
El ❑ C1 13❑
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project (Sea 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
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
LAWN SPR INKLERS - OV ER 5 (EA.) 1.00
conlmcts for such projects with a coutracH Rs) licensed pennant It,
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ l am exempt under Sec._, BLSP.C. for the
WATER HEATER W/VENT 6.00
rcaWn
Owner Dam
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO,
WATER TREATING EQUIP. 5.00
WORKERSCOMPENSA'I ION DFCLARATION
I hereby effrm that I have a cenifcate of consent to self -insure.
or a certificate of Workers' Compensation Insurance, or a candied
ZONING
ENG. SITE NO.
copy thereof( cc. 3800, b. L
Policy No. C Pany
❑ Certified copy' hereby furnished
O crlificJ c is Illeds with city xpcction division.
Appl, t o
FIRE SPRINK
Y❑ N❑
ENERGY T 24
Y❑ NE)
MISC.- REFER TO ORD. ^
PERMIT ISSUANCE 10:01t0 f�l'y
ICATIi OP.IiXIiAI PTI FROAO ORf.'E RS'
FLOOD ZONE
A.L.U.C.
COMPENSATION INSURANCE
('This section need not be cunrplmod if the permit is for o
PLG. CONTR. LIC. NO.
TOTAL •-JI
v❑ N❑
v❑ N❑
h ended dollars (S I Hot or Ices)
I certify that in the performance of the work for which this per-
n it any maoer sou as as
mit is issued, 1 shall not employ any perwa
OTY MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
9Z4N'O]'IC1i
become subject to the Workers' Compensation Laws of California.
Date—Applicant'ALTER
'10 APPLICANT: If, after making this Certificate of lix-
OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
emrfinn, you should become subject it, the Workers' Compcosa loo
provisions of the Labor Code, you must funhwlth comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (TO 10,000 C.F.M.) 4.00
FEE n
CONSTRUCTION LENDING AGENCY
AIR HANDLING UNIT (OVER 10SMCF.M.) 6.00
SEISMIC FEE
8
I hereby affirm that there is"a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
the performance of theworkfor which this permit is issued (Sec.
3097, CIv.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00 '
Lender's Name
Lenders Address
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
51 CDB
I certify that I have read this application and stare that the above
inlormarion s correct. I agree to comply with all city and.county
ordinances and .state laws rotating to buildinn cooatruction, and
VENTILATION FAN (SINGLE) 4.00
PLUMBING
I (OS
BOILER -COMP (3 H.P. or, 1 D0,D00 B.T.U.) 6.00
BOILER-COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
51
hereby
Itcrchy authorise representatives Wtivo ec on city to enter anon theith.ve
m outon4d property for,nsp of this
purpose. ts.
(We) agiee to se. e, indemnify and keep hamiless the City of
upertino again abilities, judgments, costs and expenses which
oy in any acc'Vc aga st se. City in consegee roof the
MISC. - REFER TO ORD.
CONST. TAX
�2 "74
PERMIT ISSUANCE _7-0.;00 1's
G
ranting o u pcH.
MECH. CONT. LIC. NO. MECH.
TOTAL F
TOTAL
/
entre of Applicant/Contractor Date
OFFICE COPY