18882APPLICANT TO FILL IN INFORMATION WITHIN. RED LINES -USE BALL{POINT PEN ONLY
BU I LDING PROJECT I IDENTIFICATION
APPLICATION & PERMIT
PERMIT NUMBER
BUILDING
PDDREsa
�� Al(jrBUILDING-ELECTRICAL-PLUMBING-MECHANICAL
'r
18882
OWNEDS
NAME
-' I
QTY. ELECTRIC PERMIT - FEE
PLAN CHECK VALIDATION y
PAID
NAME Acrons
UTLETS-SWITCHES -RECEP 10.00/1.00
IC. Noex .
LIGHTING FIXTURES 10.00/1.00
9
�
y
ADDRESS Tri
ADDRESS .R's CA _a/
-, 4.00,
_APPLIANCES
PANELS 10.00
g APPLICATION ".
ARCHITECT
OR
PANELS (OVER 200 AMP) 20.00
P.C. NO.
ENGINEER'
uc. No.
�•,
SIGNS TRANS. 3.00'
ADDDRESS eNc.
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
ZIP
ANT'B
APPLICDDREA
MOTORS SEE FEE SCH, .
'
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATIONj��.(,�`♦
-
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
License Cl Code en n license is in full_ ndl Nec .
Class Number a7yr�'
ISSUANCE GATE
BLDG. ELECT. PLG. MECH.
❑ ❑ O
Dae 0
Date �-� Contract
Con
BUILDING PERMIT
INFORMATION
OWNER -BUILDER DECL ATIO
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Businessand Professions
Code: Any city or county which requires a permit to construct, alter,
M R TO OR
FERMI NCE 10.00
VALUATION
S/FT.
ELEC. CONT 14. NO. ELEC.
TOTAL
Improve, demolish, or repair any structure, pOtII to Its Issuance, also
requires the applicant for such Permit t0 file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
1
PERMIT TO '
"
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) car that he is exempt therefrom and
QTY. C�UMBI NG RMIT FEE
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any viol Ion of Section 7031.$
i //
by any applicant fora permit subjects thea IicaN macivil penalty
of not more Than five hundred dollars (ES ).1:
ALTER -DRAIN -WATER (EA.) 6.00
❑ I, as owner of the property, or m employees with wages as
their sole compensation, will do thew and the structure is not
intended or offered far sulc,(Sec. 70 Business and Professions
Code: The Contractor's License Law Des not apply to an owner of
property who builds or improves Or eon, and who docs such work
himself or through his own employ a, provided that such improve-
mentsarenotmumcledoruffered or sale. If, however, the building
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
,
RESUNITS
-
DRAINS -FLOOR, ROOF, ARE CON 5.00 TrUOT
FIXTURES.- PER TRAP 5.00 �
GAS - EA. SYSTEM -11 NC. 4 OUTLETS 6.00 (M
SQ. FT. FLODR AREA
TOTALACREAGE
or improvement is sold within u c year of completion, the owner-
builder will lave the burden of roving that he did not build or im-
Prove for P. pow of sIli
❑ 1, as owner 0f the pro 'Try, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
euILDwG USE
RES IND CON PB Ocher
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to con mct tire project (Sec. 7044, Business
and Professions Code: The ontmctor's License Law does not apply
to an owner of property ho builds or improves thereon, and who
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
LAWN SPRINKLERS 'OVER 5 (EA.) ! 1.00
ASSESSORS PARCEL NO.
contracts for such proje s with a contractors) licensed pursuant t0
the Contractor's Licen Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ lam exempt un rSec. ,B.&P.C. for this
anon
WATER HEATER W/VENT ' 6.00 U(`$ .
Owner Date
WATER SYSTEM - 5.00
ACC. DATE
ACC. FILE NO:
WATER TREATING EQUIP. ' 5.00
' WORKERS'COMPENSA'I'ION DECLARATION
I hereby affirm that I have a certificate ofconsent to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereojWyS� C. Lab.C.).
Policy No/�Rj/fPi 800 La .0 I
'
FIRE SPRINK
y ❑ "N ❑
ENERGY T-24
v ❑ N❑
❑ Certified copy is hereby funishcY r
Certified c py is N with t e city inspection division.
r
pup cant�_i�r
CfiRT KATE F FROM WORKERS'
MISC.I REFER TO ORD,
PERMIT ISSUANCE 10.00
FLOOD ZONE
A. L. U.C.
E TION'INS
COMPENSATION INSURANCE
bcompleted if the permit is for one
(This section need notlCompe
PLG. CONTR. LIC. No.
PEG, �_.�ysr��
TOTAL •W
Y ❑ N❑
Y ❑ N❑
hundred dollars IS 100) or
I certify that in the peance of Us work for which this per-
MIT is issued, I shall not y any pe on in any manner so as to
QTY MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers' Compe ation Laws ol'California.
Date Appli
ALTER OR ADD TO MECH. 5.00'NOTICI?
TO APPLICANalong this Ex -
bjec rs'iompe sa
emotion, you should bec, y o the Workers' Compensation
io the Labor, y must forthwith comply with
such provisions or this peha be deemed revokeJ.
gpPL1ANCE 5.00
AIR HANDLING UNIT (TO 10,000GF.M.) 4.00CONSTRULENDING
PLAN CHECKprovisions
FEE
AIR HANDLING UNIT(OVER 10=1C.F.M.) 6.00
SEISMIC FEE
AGENCY
I hereby affirm that Tis a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
the performanceof the for which this permit is issued (Sec.
3097,Civ.C.).
MICROFILM -
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address
HEATING UNIT (OVER 100,000B.T.U.19.50
ELECTRIC
1 certify that I have read this application and slate that the above
information is correct. 1 agree to comply with all city and county
ordinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 4.00
PLUMBING
- WE
BOILER-CfJMP(3 H.P. Dr 100,000 B.T.U.) 6.00
601 LE R -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
•
(We) agree to save, indemnify and keep harmless the City of
upertino against liabilities, judgments, costs and expenses which
Try in any way accrue against said City in consequence of the
anting of Ibis mI1
CONST. TAX
"
PERMITISSUANCE 10.00
MECH.CONT. LIC. NO. MECH.
1
TOTAL
TOTAL
i are A 'ant onreactor Date
OFFICE COPY