15724 POST THIS CARD NEAR FRONT OF BUILDING PERMIT NUNIBER
CITY� OF CUPERTINO ' 15724
INSPECTION DIVISION
JOB INSPECTION-RECORD
1 / `PERMIT EXPIRATION
JOB ADDRESS /0d, 2
R) UNIT# LOT# - PERMIT EXPIRES IF WORK
OWNER ,S' {v CONTRACTOR - IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATION NOTE:
ANCE OR 180 DAYS•FROM
'
LIFER ALL GRADING AND DRAINAGE SHALL BE INSTALLED LAST CALLED INSPECTION.
PREGUNITE TO COMPLY WITH THE APPROVED PLANS AND CITY OF P_IR mn VAI.IUAnoN
CUPERTINO STANDARDS.
GARAGE SLABS '� J`•• _
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED �� , 1 v
UNDERGROUND /SLAB
PLUMBING �• .' "+
ELECTRICAL - ISSUANCE DATE
` MECHANICAL I+Loc. ELECT I PLG. MECH
`❑ ❑ ❑ ❑ '
00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
WOOD FLOOR .
INFORMATION..
.VALUATIONsiFr.
PLUMBING
MECHANICAL
ELECTRICAL - - sPrE R�n+IS To
FRAMING-
INSULATION
STORIES TYPE CONSTR.
� � - -
D
PI OtOLE GROUP RES UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED ""
SO.FT ILOORAREA TOTAL ACNEAGE
ROOF NOTE:NO FINAL INSP.SHALL BE MADE BEFORE
DIAPHRAGM THE CONSTRUCTION TAX IS PAID
BUILDING USE
ROOF SHEATHING I - Ires IND CON Peuu...,
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED FINALS DATE INSP. 11 -E] ❑
ASSESSORS PARCEL NO
' ROUGH SAN.H '
PLUMBING ELECT.ENERGY
TRACT NO. PARCEL NO
TUBS IS SHOWER PAN PLUMBING-ENERGY
MECHANICAL MECH.ENERGY
ELECTRICAL - — BUILDING ENERGY . - ACC DATE ACC.FILE NO
FRAMINGELECT.FINAL TEST
ZONING ENG.SITE NO,
INSULATION PLUMBING
GAS TEST GAS
FIRE SPRINK ENERGY T 24
MECHANICAL Na
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING YE) No Y Cl
FLOOD ZONE A-L U C. `
EXTERIOR SHEAR ELECTRICAL RELEASE ,� C47,
INTERIOR SHEAR FIRE DEPT. r NO Y ❑ No
SHEETROCK - GRADE - FEE SUMMARY
EXTERIOR LATH BUILDING -
INTERIOR LATH TEMPORA Y APPROVALS
BUILDING 4 -I
SCRATCH COAT ELECTRIC. . PLAN CHECK
GAS FEE
+ NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY - SEISMIC FEE
OCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUI LDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY-PHONING 252.4505, ELECTRIC
H� ONE WORKING DAY'BEFORE REQUIRED INSPECTION.
�� O PLEASE GIVE JOB ADDRESS WHEN PHONING. PLUMBING
p 'd' Z - SEE PERMIT FOR EXPIRATION DATE - MECHANICAL
IMPORTANT! CONST.TAX
PLEASE READ REVERSE SIDE BEFORE ' . TOTAL !Z
CALLING FOR FINAL INSPECTION.
OFFICE COPY
APZoL--ICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
r BUIDz GPRO2TFICATIO ' .
PERMEENUMBER
BUILDINGBoe ,ac APPLICATION & PERMIT
DENT
AbDRESa Jr
15724 -
1 BUILDING- ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S , PLAN CHECK VALIDATION
NAME / u �8 72/-3 s72 QTV: ELECTRIC PERMIT FEE
James (_ PHpNF(P-P)X;
- 7/ 1 /
CONTRACTOR'S l
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
AlLI C.NO, LIGHTING FIXTURES 10.00/1.00
CONTRACTOR S APPLIANCES-RESIDENTIAL 400
ADDRESS
Iv PHONE PANELS 10.00 DATE OF APPLICATION.
ARCHITECTQ- - PLAN CHECK FEE PG..NO.
OR PANELS (OVER 200 AMP) 20.00
GINEEfl -
EN -
LIC.No. ISIGNS TRANS. 3.00
ARCH.OR ENG. - PERMIT VALIDATION
ADDRESS A(//4 ZIP
CIRCUIT 5.00
zIP EMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS
ADDRESS SEE FEE SCH. .
. .' pW N Q✓S ) SERVICE CHANGE - 20,00 ��{ev,
Foo LICENSED CONTRACTORS DECLARATION "
a u I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
11 (comntemmjig with Section 7000)of Division 3 of the Business and
BLDG. ELECT, I PLG. MECH.'
r w z Professions Code,and my license is in full force and effect.
z ❑ El Elm License Class m
Lic.Nuber
Date Contractor
a y,s 4 - BUILDING PERMIT
¢ 0.6 U OWNER-BUILDER DECIARA'f1ON INFORMATION
X
3 u m I hereby affirm that ].am exempt from the Contractor's License MISC. REFER TO ORD
LL o to j Law for the following reason.(Sec.7031.5,Business and Professions VALUATION $/FT.
H _ PERMIT ISSUANCE 10.00
Code:Any mulish wr rep which Tinnituse Penni[LLS construct,alta,
Q Sao improve, or repair any structure,prior to its issuance,also ELEC.CONTE. LIC. ELEC.
i E ¢ IS requires the applicant for such permit to file a signed statement that TOTAL
w m" he is licensed pursuant to the provisions ofLicense,the Contractor's PERMIT TO
iii Law(Chapter 9(commencing with Section 7000)of Division 3 of the
4 o Business and Professions Code)or that he is exempt therefrom and LUMBING PERMIT FEE
¢ H m the basis for the alleged exemption.Any violation of Sed ion 7031.5 QTV. P
5 TYPE CONSTR.
n ; � by any applicant forxpermit subjects the applicant loacivilpenally ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
r ❑ I,as owner of Ile properly,or my employees will,wages asBgCK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for IS (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or f rproves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT FLOOR AREA _ TOTALACREAGE
himself or through his own employees,provided that such improve-
fF ponosaremol intended.,Offered lot sole.If,howeveq the hudding GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
r or improvement is sold within one year of completion,the owner- GAS-EA,SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that h .
e did not build of int. BUILDING USE
prove for
s owner RES IND CON PB Other
Df sale.). INDUSTRIAL WASTE INTER. 30.00 El ❑ I] E
O I,as owner of the property,am exclusively contracting with
licensed contractors to rcm,bud the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
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-OVER 5(EA.) 1.00
contracts frit such projects with a eonhnetor(s)licensed pursuant 10
the Contractor's Lf se tpVw SEWER-SANITARY-STORM EA.200fT/10.00 TRACT No. PARCEL No.
❑ I a t cxemp a dqy B.&I'.C.for this
reason ,,"1t_/yWATER HEATER W/VENT 6.00
""
� r IDate=tV--d`rWATER SYSTEM 5.00
ACC.GATE ACC.FILE NO,
WORKERS'COMPE,NSA'IION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconsant to self-insure, ZONING ENG.SITE N0.
or a certificute of Workers'Compensation Insurance,or o et'lified
copy lhereof(Sec.3800,Iab.C.).
Policy No. + Company
O ❑ Cerlilied copy ishereby furnished. FIRE SPRINK ENERGY T-Z4
Z Z . ❑ Certified copy is fled with the city inspection division.
FO Applicant MISC.- REFER TO ORD. Y [] N� Y ❑ N[
CERTIFICA'I'fi OI'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE 'A.L.U.C.
W COMPENSATION I NSURANCE PLG.CONTE. LIC.NO. PLG,
Q' 0 (This Section need not be completed if the permit is for one TOTAL Y(-] NF Y ❑ N
M Z hundred dollars IS 100)or less.)
U O 1 certify that in IIIc pcd'ormance of the work Bm which this per- OTV MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of Calil'nrniu.
M Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} Va NOTICE'1'O APPLICANT': If,after making this Certificate of Ex-
H ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you nulst forthwith comply with - FEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT TO 10,000CF.M.) 4.00
CONS"FRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0MC.EM.) 6.00 SEISMIC FEE 1547-
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work.for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's 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 VENTILATION FAN (SINGLE) - 4.00
information is correct. I agree to comply with all city and county PLUMBING
f; ordinances and state laws totaling to building construction, and BOILER-COMP(3 H.P.Of 100,000 B.T.U.) 6.00
hereby autlmri,c representatives of this city Io enter upon the BOILER-COMP IOvar 100,000BTUISEE FEESCH. MECHANICAL
above-mentioned property for inspection pugmses,
(W e) afireo sav-, 1 demnlfy and keep harmless the City of MISC.- REFER TO ORD.
Cupertino � air t Iia ;I s,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
'y in w ya, gp{Tu6l sold City in cnnse9ucnee of the
R pe (/_„- MECH.CONT. LIC.NO. MECH.
VB VY TOTAL TOTAL so]
ign tureof Applfcunl/Contracto Uair
OFFICE COPY
ADDITIONAL PERMIT FEES
BUILDING PROJECT IDENTIFICATION VALUATION
BUILDING
ADDRESS D�n
OWNEII 1
NOME FEE SUMMARY
CO gMes {�LNE
F Irons
.A. BUILDING
NA
�0 PLAN CHECK
DOB'S FEE
ADDRESS DDRESS
ONEu `/
/'� rxoxE SEISMIC FEE
OTV. ELECTRIC PERMIT FEE
UTLETS-SWITCHES-RECEP , Ov ELECTRIC r
LIGHTING FIXTURES 1K� ' Of" PLUMBING
PPLIANCES-RESIDENTIAL
PANELS MECHANICAL
SIGNS
SIGNSTRANS. TOTAL
SPECIALCIRCUIT d
EMP.METER OR POLE INS. rEnmlT VALIDATION
MOTORS SEE FEE SCH.
SERVICE CHANGE
z 2Ari$ 0
F a TOT ^n
ISSUANCE DATE
LU > OTV. PLUMBING PERMIT FEE BLDG. ELECT, PLG. MECH.
=) 2 ALTER-DRAIN&VENT-WATER(EA.) ❑ ® ❑
U O BACK FLOW PROTECT.DEVICE
LL
O W DRAINS-FLOOR,ROOF,AREA,CONO.
>_ ti FIXTURES-PER TRAP
F ? GAS-EA.SYSTEM-l1NC.40UTLETS
V GAS-EA.SYSTEM-OVER 4(EA.)
INDUSTRIAL WASTE INTER.
LAWN SPRINKLERS-1 INC 5 V.B.
LAWN SPRINKLERS-OVER 5(EA.)
SEWER-SANITARY-STORM EA.700tt/
WATER HEATER W/VENT
WATER SYSTEM
WATER TREATING EQUIP.
TOTAL
OTV. MECHANICAL PERMIT FEE
ALTER OR ADD TO MECH.
APPLIANCE
AIR HANDLING UNIT(TO 10=C.F.M)
AIR HANDLING UNIT(OVER 10=C.F.M.)
EXHAUST HOOD IWITH DUCT)
HEATING UNIT(TO 100,000 B.T.U.)
HEATING UNIT(OVER 100,000 B.T.U.)
VENTILATION FAN (SINGLE)
BOILER-COMP O H.P,o,100,000 B.T.U.)
801 LER-COMP law"IOD,WD BTUI SEE EEE SCH.
TOTAL
I ,
POST THIS CARD NEAR'FRONT OF BUILDING ,
PERMITNUMBER
CITY OF CUPERTINO 14712
INSPECTION DIVISION
JOB INSPECTION RECORD
PERMIT EXPIRATION
JOB ADDRESS 10294 S. STELLING ROAD UNIT# _Lor#
--PERMIT EXPIRES IF WORK
-- OWNER 'JAMES LU CONTRACTOR IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU• '
FOUNDATIONANCE OR 180 DAYS FROM
NOTE: LASTCALLED INSPECTION.
UFER ALL GRADING AND DRAINAGE SHALL BE INSTALLED _ _
PR EGUNI?E TO COMPLY WITH THE APPROVED PLANS AND CITY OF Pta ATION
CUPERTINO STANDARDS.
GARAGE SLABS -
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED - v• `/. 44 /f lv Lr Kell, FF�' g � 1ps
UNDERGROUND /SLAB Q/!C2 %j✓ flror7 1-t,-T_'�s.4-I I Lb_-(,I0
. PLUMBING - City of Cupertino
ELECTRICAL - - ISSUANCE DATE
MECHANICAL - FLOG 11-ECT PLO' I MO
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
WOOD FLOOR VALUATION SIFT:
PLUMBING
MECHANICAL
ELECTRICAL �^ yy veHmn rO
FRAMING �W
INSULATION
STORIES TYPE CONSTR,
- - ,
-
OCC.GROUP RES UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF NOTE:NO FINAL INSP.SHALL BE MADE BEFORE SO.FT FLOOR AREA TOTAL ACREAGE
DIAPHRAGM THE CONSTRUCTION TAX IS PAID
BUILDING USE
ROOF SHEATHING RES IND CON PB. 0"',
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED FINALS DATE INSP. ❑ ❑ ❑ ❑ ❑
_ ASSESSORS PARC EL NO
ROUGH SAN.#
PLUMBING. - ELECT.ENERGY
TRACT NO. PARCEL NO
TUBS BSHOWER PAN PLUMBING ENERGY '
MECHANICAL - MECH.ENERGY
ELECTRICAL BUILDING ENERGY ACC..DATE ACC.FILE NO ,
FRAMING - ELECT.FINAL TEST
ZONING ENO.SITE NO.
' INSULATION PLUMBING
GAS TEST GAS
MECHANICAL
FIRE SPRINK ENERGY T,24
❑
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING Y ❑ NY [:] No
FLOOD ZONE A.L.0 C.
EXTERIOR SHEAR � ELECTRICAL'RELEASE
INTERIOR SHEAR FIRE DEPT.
❑ . N❑ ❑ N❑
SHEETROCK GRADE FEE SUMMARY
EXTERIOR LATH BUILDING -
INTERIOR LATH TEMPORARY APPROVALS BUILDING .
SCRATCH COAT - ELECTRIC. PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY - SEISMIC FEE
OCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM
_ ARRANGE FOR.INSPECTION BY PHONING 252-4505, ELECTRIC `f"
H ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
n 0. PLEASE'GIVE JOB ADDRESS WHEN PHONING. .
— SEE PERMIT FOR EXPIRATION DATE — MECHANICAL,
IMPORTANT! ; CONST.TAX
'PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION. J_
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER j
Dn-DING
'APPLICATION & P.ERMIT - A A r� 2 n -i
ADDRESS%O�// S, to In Rea I L} r
/T, J BUILDING —ELECTRICAL—PLUMBING—MECHANICAL
M- OWNER'S '-37U2 !P PLAN CHECK VALIDATION
NAME /gymjJ� ELECTRIC PERMIT FEE
Uf/Ees I/. PHDNE�V -.JUb -
,7a., COONTRACTOR'SUTLETS-SWITCHES-RECEP 10.00/1.00
AME �N LIC.No. LIGHTING FIXTURES . 10.00/1,00 -
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDREss _
PHONE PANELS ' 10,00 DATE OF APPLICATION
ARCWTECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
' LIC.NO SIGNS TRANS. 3.00 '
ADDRESS ENG. SPECIAL CIRCUIT 5.00 depITlyquonnoN
ARCH.OR
ZIP EMP.METER OR POLE INS. 20.00
AREMOTORS SEE FEE SDH. - F{7j , -'�9a(�w,r,•N/r/�
ADDRESS
SERVICE CHANGE 20.00 1ysV�F•'s�— ,k"1J
0 0 o LICENSED CONTRACTORS DECLARATION City (I! Culler IIIIO
se U U I hereby affirm Ihul 1 um IicenuJ under provisions of Chupmr 9 ISSUANCE DATE
r a (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
rw i Professions Code,and my liceme is in full force and effect. ❑ ❑ ❑
z o w- License Class Lie.
o z F Date—Contractor -
aNumber-
lo Ems, BUILDING PERMIT
¢ 2 w OWNER-BUILDER DECLARATION INFORMATION
w ;LL N 1 hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD
u0¢ Law for the following reason.(Svc.7031.5,Business and Pon cessions PERMIT ISSUANCE 10.00 . O va WAT10N S/FT.
cow Code:Any city orcounty which requiresa permit toconstrucL alleq _
pimprove,demolish,or repair any structure,prior to its issuance,also ELEC.CONTH. LIC.NO. ELEC.
K c u requires Ilse applicant for such permit to file u signed statement that TOTAL - 20 PERMITTO
w m he is licensed pursuant to the provisions of ole Contractor's License
z a Low.(Chapter?(commencing with Section 7000)of Division 3 ofthe
E i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE 11..�7LL/
m r o the basis for the alleged exemption.Any violation or Section 7031.5 STORIES TYPE CONSTR.
i ; m by any applicant for a pennit subjects the applicant to a civil penalty
ALTER-DRAIN&VENT-WATER (ER.) 5.00
of not more than five hundred dollars($500)):
❑ I,as owner or tie property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 C.
their sole compensation,will do the work,and the structure is not OCGROUP RES.UNITS
intended or offered for sole(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5,00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided that such improve-
merits
mprove- .
himself a not through
ho own
et,i,ar provided thm achebuilding GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2:00
builder will have the burden of proving that he did not build or am- BUILDING USE
prove for purpose of sole). INDUSTRIAL WASTE INTER. - 30.00 RES IND CON_ PS Doer
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ` ASSESSORS PARCEL NO.
and Professions Code:The Contractor's Licenu Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) '1.00
contracts for such projects with a contractor(s)licenwd pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 ,TRACT NO. ,PARCEL NO.
❑ I am exempt under Sec. ,B,KP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Mmes _ Dale WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORK ERS'COMPIiNSAT10N DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a cerllficateof ennsent to self-insure, ZONING ENG.SITE NO,
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lb.CA
policy No. - Company
O .❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T24
Z Z ❑ Certified Copy is fled with tire city inspection division. MISC.- REFER TO ORD.
0 ApplicantY ❑ N❑ Y'❑ N❑
a CURTIFICA'rE 01°EXEN1P1 ION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
>_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL 0 (This vetidn need not be completed if tire permit is for one TOTAL ' Y❑ N❑ Y ❑ N❑
Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which Ihis per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
Ul I- ntit is issued, I shall not employ any person in any manner so os m
U become subject m the Workers'Compensation Laws of California.
Q a DateApplicant ALTER OR ADD TO MECH. 5.00 BUILDING
m NOTICE TO APPLICANT: IL after making this Certificate of F.- •
F. ? enlption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
pi-nimona of the Labor Code, You must forthwith comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER I0,000GEM:16.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which Ihis permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.C).
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
;t I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
d, ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,0008.T.U.1 6.00
T'4 hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-maNioned property for inspection purposes.
- (We) agre to save, indemnify and keep harmless lire City of MISC.- REFER TO ORD.
CU mono 'i s T' lilies,judgments, costs and expenses which PERMIT ISSUANCE o 10.00 CONST.TAX
*� ,"01
c rue against said City in consequence of the s LMECH.CONT. - LIC.NO. MECH2-LS �- - TOTALTOTAL
Applicant/Contractor, Un[e
OFFICE COPY