3842 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI. POINT PEN ONL Y
PE IT NUMBER
BU I LDING PROJECT I DENT]FICATION APPLICATION & PERMIT ER
aUILOING -
ADDR
S I tt 3842
10300 Tantau Avenue
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S - I4jrt' f.` PLAN CHECK VALIDATION
IN
RI
p OTY ELECTC PERMITI ;'Sx FEEk
Vallco Park' .,.,253-4550
NAME aoR3 UTLETS-SWITCHES-RECEP 5.00/1.00
NAME
Orwin Engineering,,.,..150751 LIGHTING FIXTURES 5.00/1.00
CONTroNrflncrlR's PPLIANCES-RESIDENTIAL 4.00
ADDRESS
3271 Kifer,S.C. PHONE 732-219 PANELS 5.00 DATE OF APPLICATION
ARCHITECT 6.00 PLAN LHECK FEE D.C.NO.
!fl SIGNS
ENGINEEfl
LIE.No. ISIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ES
ADDRESSIIP EMP.METER OR POLE INS. 15.00 9-2;V-S
aPPLICATS95051 MOTORS SEE FEE SCH.DDIR ESS
3271 Kifer Rd. Santa Clara SERVICE CHANGE 10.0000 LICENSED CONTRACTORS DECLARATION ���
Q u u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
iProfessions Code d icense is in full fore n ❑ ❑ ❑ ❑
i
L ; Licen I Lic.Number
N F J ,
Dale Contractor
se ¢ at OWNER-BUILDER DECLARATION (!" S,cBU1LDIRM TION I,
o a MISC.- REFER TO ORD <•.. INFORMATION
y I hereby affirm that I am exempt from the Contractors License VALUATION SIFT.
LL0 Law for the fallowing reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 6.00 C
Code:Any city or county which requires a permit to construct,alter. Y 7 7 5.0 0
improve,demolish,or repair any structure,prior to its issuance,also ELEC CONTR. LIC.N0. ELEC.
L
O LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
m he is licensed pursuant to the provisions of the Contractor's License s
i Law(Che ter 9(commencin with Sect ion 7000)of Division 3 of the Y8' 3-`v b In ; w.•!arae f1 ' /eQfj�
H a Business and Professions Code)or that he is exempt therefrom and OTV "h - -PLUMBING PERMIT ;1.. (I).v'r ray FEEIs,
0 the basis for the alleged exemption.Any violation of Section 7031.5 ,9r- aims _✓4k.'...' .: :' Y •.v -. d+ STORIES TYPE CONSTR.
a3 by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00 of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 DCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for Sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 4.00 SQ FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
( ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
* or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
REB IND CON PB Other
prove for purpose of sale.).
❑ [,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ 0 ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS•OVER 5(EA.1 1.00
contracts far such projects with a contractosls)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. .BAP.C.for this WATER HEATER WIVENT 4.00
eason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate ofconsent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance.or a certified
copy there! f f -]SOp�Lab,(1.
Policy N rt Lis hereby
❑ Certified copy is hereby famished. FIRE BPRINK ENERGY L24
Certifiedd coppy is file�wilh,tlte nt' inspection division.
ZO Appicant (7rVln M'llgl nrlW ng MISC.- REFER TO ORD, y N� Y [] N�
� y CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE - 6.00 FLOOD ZONE A.L.U.G.
d 0 COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG. v[] N� v ❑ N�
(This section need not be completed if the permit is for one TOTAL
2 hundred dollars IS 100)or less.) - - -
U O 1 certify that in the performance of the work for which this per- DTV. . -„MECHANICAL PERMIT - FEE FEE SUMMARY.' -
tl: F mil is issued,1 shall not employ any person in any manner so as m _ ,• -
O became subject to the Workers'Compensation Laws of California.
y Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING 14.50
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE 9 .43
U such provisions or this permit shall be deemed revoked. I AIR HANDLING UNIT TO lO,GOD C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIRHANDLINGU_IT(OVER I0,000GEM.) 5.00 SEISMIC FEE 550
1 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. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ.C.). None
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
Information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.or 100,000 B.T.U.1 4.00
tC.Pc
herebyauthorize representatives of this city to enter upon the g01 LER-COMP (Over 100,000 BTUI SEE FEE SCH. MECHANICAL
bove-mentioned property for inspection Purposes.
(We) agree to Save, indemnify and keep armless the City of MISC.- REFER TO ORD.
rtino against liabilities,judgments, co sand expenses which CONST.TAX
ay in y way accrue against a Ci consequence of thePERMIT ISSUANCE 3.00
ra this Permit MECH.CONT. LIC,NO. MECH. 24 .43
7/13/ 3 TOTAL TOTAL ,
Si ' ore of Apphwnt Commet r Date
James W. McGr6g , Vice .Press en OFFICE COPY