5415 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE, BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BRAIDING -1
RAPPLICATION & PERMIT
ADDRE6 \ - 5415
1. I.OS O BUILDING ELECTRICAL-PLUMBING-MECHANICAL ..
I OW ER'S - - PLAN CHECK VALIDATION
NAME \J MIN
EI!E TRICPERMIT Wkm
FEE
QY rev I
NrRACTaRs UTLETS_SWITCHES-RECEP 5.00/1.00
NAME 1�'//�
1 �• h 0101 .No.Lf 3' LIGHTING FIXTURES 5.00/1.00
c NTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
ADDR F55
D l�qs W A -c- PHONE ? -C,3DY 'PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 600 PLAN CHECK FEE P.C.NO. .
Ofl "
ENGINE.EP
uc.n0. SIGNS TRANS. " 7.00
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS- 15.00 '
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH. A(D
SERVICE CHANGE 10.00
I,N I CI �[ //'
DDa LICENSED CON'FRACfORS DECLARATION U. �D .A ROE7� [fB,I
re U I hereby arfirm that I am licensed under provisions of Chapter 9 ISSUANCE DA E D `t
may (commcncmg with Section 7000)of Division 3 of the Business and' BLDG. ELECT. PLG. MECH.
'H m z Professions Code nd y�mo�se is in full for a d effec ( V t ❑ (
z D w
Lice nv: his-/�.� �/_Lic.Number 1) 1 B
L
tIACt
o w r w Dale IY-1 Contractor-J_)�'��
a Y BUILDING�PERMIT
M a w a OWNFR-BUILDER DECLARATION INFORMATION
od" - MISC.- •''REFERTO ORD
EL
g a.ta I hereby affirm that I am exempt from the Contractors License VALUATION $/FT.
LL o a Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
w Code:Any city or county which requires a permit to construct,alter, " ' (, `//0 O
IF
rt ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. - EIEC, r
to O m requires the applicant for such permit to file a signed statement t11 t TOTAL PERMIT TO-
°' Kin,
u he is licensed pursuant to the provisions of the Contractor's License
a Law(Chapter 9(commencmgwith Section 700()orDivision 3 iflhux". 5�.
io Business and Professions Code)or that he is exempt therefrom and OT Y;"Ne� eg ffi P.LUMBING,�,.,PJERMIT F,
F the beaK for the alleged exemption,Any violation nl Section 7031 $ 4J� . -lr v1k k P„ ,N'.4 WSW $�.., .r. �.v t - STORIES TYPE CONSTR.
• a ; � by any applicant fora pervtit subjects the applicant toncivi1 penally ALTER-DRAIN&VENT-WATER (EA.) 4.00
- 4r-2) A.O�
of not more than five hundred dollars S5000.): q C
❑ Las owner at mo property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 O GROUP RES.UNITS
their sale compensation,will(S the work,and the structure is onotns _
CodeW or ontrcddor laic (Sec. 7044, nosiness and Professions DRAINS-FLOOR;ROOF,AREA,COND. 4.00 property
The Contractor's License Law does not apply to an owner of
�. himselfy Whohn11dhis improves
emplo employees,
provided
who dnee S4dl Wolk'; FIXTURES-PER TRAP 4.00 6D.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided that such improve-
ments
mprove
mems are not intended or offered for salt.IL however,the building 'GAS:,.EA,SYSTEM-11NC.40UTLETS 4:00
or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 ` BUILDING USE
builder will have the burden of proving that ho did not build or ire- BUI
'= - .R E6 IND CON PB OrM1ar_
.
prove lot purpose of sale.). - INDUSTRIAL WASTE INTER . 20.00
❑ I,as owner of the property,em exclusively contracting with. ' ❑ ❑ ❑ . ❑ ❑
licensed contractors to construct the project(Sea 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 A66Es$oR&PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to air owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00 '
the Contractor's
License
Lwitha conlmctods)liconsed pursuantto SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the Co t,for such
Lieeose Law.
❑ I am exempt under Sec. ,BAP.C.for thus WATERHEATERW/VENT - 4.00
reason
Owner -Date. WATER SYSTEM'' 4.00 ACC.DATE ACG FILE NO.
WORKERS'COMPP-NSATION DECLARATION WATER TREATING EQUIP, - 4.00
I hereby aflirm that I have a Certificate of consent to self-insure, -
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab C.).
Policy No. Company
b' ❑ Certified copy is hereby furnished. FIRESPRINK ENERGY T24
'z. ❑ CVificd copy is filed with the city inspection division. MISC. REFER TO ORD,
O Ahplicnnl Y ❑ N❑ Y ❑ N❑
~ RS
!r - CERTIFICATE 'COMPEFNSSAPERMIT ISSUANCE _ 6.00 FLOODZONE A:L.U.C.
AI TIOOTION FROM WORK F:
> N INSURANCE PLG.CONTR. � LIC.
S O (This section need not be completed if the permit Is for one TOTAL - Y❑ N❑ 'Y ❑ N❑
Z hundred dollars($100)tor less.) '
(> O ( certify mut in the performance of the work for which this per OTVs s'^ 'e" MECHANICAL�PERMT •e
,P 'x4a`#WFEE ,"1;-' ' FEE.UMMA'RVgs
LL F mit Is issued,I shall not employ any person in any manner so as to R a -Ili 4"`•,§•A+ - n= y+ b+, V v'
U Neem • A e'l o mWorke ensation fCu' I.
U.1 Uate"Applican '"-" �{p��/ ALTER OR ADD TO MECH. 4.00 BUILDING
} m NOTICE T PI' (CANT I ue CcrUflcalc of Ex-
mak,Z Cmption,you should become subject'lb the Workers'Compensation APPLIANCE _ 4.00 PLAN CHECK
Provisions of fire Labor Code, you must forthwith'complywith - - - FEE'
•U such provisions or this permit shall be deemed revoked. _ AIR.HANDCING UNIT(TO 10,000 C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVERi0=C.F.M.) 5.00 SEISMICFEE '
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
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.) 4.00
Lender's Name - HEATINGUNIT(OVER 100,000 B.T.U.)7.50 '
-Lender's Address ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and County - PLUMBING '
U.) 4.00
ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.or1OO,000B.T.
hereby authorize representatives of this city to enter upon the 'BOILER Mar(Over'100,000 BTU(SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes.-.
(We) agree to save, indemnify and keep harmless the-City of MISC. ,1 REFER TO ORD. -
Cuperlino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
granting of this permit . MECN.CONT , 'LIC.NO. MECH.
60
ol'App t/ on ractor Dal s TOTAL
tlOFFICE COPY