9262 AVVLIL:/AIv I 1 lJ CILL IN IIV1'l nln 1 lulu agl In I Iva 1-IcZU LIIVCJ - UJC LIALL rLJI1\1 I t'LlTxl VIUL 1
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
n nD0RE55
C 1 BUILDING - ELECTRICAL- PLUMBING-MECHANICAL 9262
OWNER'S -,_�I/� .
ME v ' c I;Jj, PLAN CHECK VALIDATION
QTY. .ELECTRIC PERMIT 1/'1 t P x L FEE',,
±61`606,111'aL P f . { rr,,zr
NAME AcroRs UTLETS-SWITCHES-RECEP 10.00/1.00
Lie.NO. LIGHTING FIXTURES 10.00/1.00
ADDRESS row's PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
oil PANELS (OVER 200 AMP) 20.00
ENGINEER
uc.No. SIGNS TRANS. 3.00
ADDRESS E.G. SPECIAL CIRCUIT 5,00 PERMIT VA0 JDI'
ZIP EMP.METER OR POLE INS. 20.00 PAA l�
AVORCSS MOTORS SEE FEE SCH. JUL 1 f1pC�
SERVICE CHANGE 2 V '4 �' �`3v`e
Woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
Cityof
DATA of Cuertino
a i W I hereby affirm chat I am licensed under pruvisions of C'hupter 9 1 55 CE
N < w (commencing Willi Section 7000)of Division 3 of the Rosin.,and BLDG. ELE T. MECH.
r N z PmfessionS Code,and my license is in full force and effect. ❑ ❑
o n i lit W License Class Lic.Number
Date Contractor
or a'W a OWN ER-B UI LDER•DECLARATION "qkl ' BU DING'PERMIT:,".,dC,:
K o,, eJ ;$�sii�i+. I FORMATION;:!'t'k:;s'�'
w ; N 1 hereby affirm that I am exempt from the Contradur's License MISC.- REFER TO ORD
u O st Law for the following reason.(Sec.7031.5,Business and Professions VALUATION $1FT.
- PERMIT ISSUANCE /
,.,y Code:Any mulish....y whiny structure.
requires une permit prior
t o" SSUUECC.also
Q Q ¢ IIIIpIOVe,demolish,Of repair any 5[rUelnre,PtlOf tO 1[S If Sllallce,aI30 ELEC.CONTR. LIC.NO. ELEC.
E m a,requires the applicant for such permit to file a signed SUCHicnl thatTOTAL
6 W he 1S licensed pursuant to Zile Provisions Of IIII'Cunlracl V!s License �I PERMIT TO
L.-(Chapter 9(1o111n1t,neing with Section 7000)uf Division 3 ullye - {/
P ¢ Business and Professions Code)or that he is exempt Ihefefrual and OTY. PLUMBING PERMIT ��FEE,'„ /
¢ H om Ilse basis for the alleged a%cmpli0n.Any viOlulinn.1 Section 7031.5 T RIES TYPE NSTR,
n byanyapplicanifor a permit subjects the applicant lou civil penally ALTER-DRAIN&VENT-WATER
of not nmre thou live hundred dollars(8500).): (EA.) 5.00
❑ 1,as..net of the property,Or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will(S the work,and the Strut Due el nut
Code:Ttended he
offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Conlnclor's License Law dOCS 00I apply IO all UWIICr OI
property who builds or iHIii thereon,and Willi does Such work FIXTURES-PER TRAP 5.00F
S FT.FLOOR ARE A TOTAL ACREAGE himself or through his own employees,provided that Such improve-
mems are not intended or offered for sale 11;however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6,00
lir improvement is sold within mon year of completion.Ile owner
build will hove the buNen of-proving I ta(he did not 1p)i�d or ins- + GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
p v I'urpurpom ER sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB On.,
I as Owner of file property,am exclusively conlmcling with
P
lf uacrofs to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCELNO.
ofessionsCode:Tile Conlndor•s License Law dues not applyowner of properly who builds or improves Ihercon.and who LAWN SPRINKLERS-OVER 5(EA.) 1,00
os for such projects with a Contractorfs)licensed purxlanl to
Il• ' nuactoi s License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
❑ Icon exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 6.00
reason_
owner Uwe _ WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO,
WORKERS'('OMP.NSA'TIONE EC'I.ARA1111 WATER TREATING EQUIP. 5.00
I hereby affirm that I have a cerlilicate of cmuem to 01fin sun,
o!a certificate of Workers'Compensation Inslmnce,H, a vellifi,d ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lxb.C).
Policy Nu. C'Dlnpuny
0 Cl Certified copy is hereby furnished. FIRE SPRINK ENERGY TZ4
�
z Z ❑ Certified copy is filed Willi the city inspection division. N[]0 Applicant MISC.- REFER TO ORD. Y N Y RG
it C17RTIFICATI:OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE FLOOD ZONE: A.L.U.C.
LL COMPENSATION INSURANCE PLG.CONTH. FIC-NO PLG,
Cl (Phis' Section need not be Completed if the N�
Z P pennil is Im one TOTAL Y N Y
U O hundred ern dollars(n tale pe Iva.[
I is•issu that ns tile to employ
an of Ibe work for which this per. QTY. MECHANICAL PERMIT '.'.FEE,
,FEE SUMMARY
LL H mit is issued,I shall not employ om person in any .1manner Cahlso as to :
CO become subject to Ifle Workers'Compensation Laws ol'Calilbmiu. - u' ,
co Dale APPLICANT:
I ALTER OR ADD TO MECH. u-5.00 BUILDING
} co NO'IICC TO AI'I'LICANT�, If,ufmr making This Certilic:nc of I:x-
Z coop tion,you should beenme subject Vile Workeri C'umpensalion APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Cade, you Hills[ forthwith comply Willi
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm [flat there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
tile performance of the work for which this Penni[ is issued(See. MICROFILM
3097,Civ.C.E 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
Icertify lot l have read this application and State(flat the above VENTILATION FAN (SINGLE) 4.00
illumination is correct.1 agree to Comply With all city and county PLUMBING
ordinances and sink, laws relating l0 building consNuclim, Pull BOILER-COMP(3H.P.Dr100,000B.T,U.) 6.00
homily authorise representatives of This oily to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-men[inned property for inspection purposes.
(We) gree to save, indcmn'1'y and keep harmless tlm City of MISC.- REFER TO ORD. -
CuperE against liabilities, 'wn1tn mats anJ expenses which CONST.TAX
may - anY waY aecr ai t s:i ity in cmisvfuence of Ibe PERMIT ISSUANCE 10.00
gm I f this Pe -/ MECH.CONT. LIC.N0. MECH.
TOTAL o;4,••
TOTAL
i rc n App .n GnurudDr Uute .U; '.. :. ,
OFFICE COPY