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14430 (5)(CANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT I DENTI FICATION APPLICATION &PERMIT BUILDING - ELECTRICAL- PLUMBING - MECHANICAL PERMIT NUMBER •- 14430 � � 3'� BUILDING + a+;DUREss 0 NER'S NINEis DTV. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION PHONE coNTRACT r' QA1O UTLETS-SWITCHES-RECEP 10.00/1.00 LIGHTING FIXTURES 10.00/1.00 rONE cTo 's CO APPLIANCES- RESIDENTIAL 4.00 NEIL� 71I� 1`I,J DATE OF APPLICATION PANELS 10,00 ARCHITECTPANELS OR ENGINEER LIC, No. (OVER 200 AMP) 20,00 PLAN CHECK FEE D.C. NO. SIGNS TRANS. 3.00 AENG, ADDRESS REss 500 SPECIAL CIRCUIT , PERMIT VALIDATION fTEMP. METER OR POLE INS. 20.00 ZIP It" APPLICANTS ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 hICENSIiU CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE (cmaaaencing with Section 7000) of Division 3 of Iho Business and BLDG. ELECT. PLG. MECH. Professions Co��6jE.Ipdyny license is in full to c •cfq 0 License Class C-5 II _ Lic. Ni.M1UI K_ %q - Datc.��q��_Contmctur_ ❑ ❑ ❑ BUILDING PERMIT OWNIiwnUILD1iR DECLn RA'PION I hereby alirm that I a exempt from the Contractor's License Law for the following rc.son (Sec. 7031.5. Businessand Professions INFORMATION MISC. - REFER TO ORD VALUATION SIFT. PERMIT ISSUANCE 10.00 Code: Any city or county which requires a permit to construct, alter, improve, demolkh, or repair any structure, prior to its isslronce, also ELEC. CONTR. LIC. NO. ELEC. requires the applicant for such permit to file a signed statement that he is licenced pursuant to the provisions of the Contnactor s License TOTAL PERMIT TO � PLUMBING PERMIT FEE Law (Chapter 9 (commencing with Section 70000of Division 3 of the Business and Professions Code) or that he is exempt therefrom andQTY. the basis for the alleged exemption. Any violation of Section 7031.5 STORIES TYPE CONSTR. ALTER -DRAIN -WATER (EA.) 5.00 by any applicant for a permit subjects the applicant toa Civil penalty of not mor" than Use hundred doll... 155001.1: ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business nand Professions Code: The Contractor's License Law does ot apply to an owner of property who builds Or improves(hereon, and who does such work BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA,CO D. 5.00 d _ FIXTURES - PER TRAP 5.00 S gO, IT, FL001 AREA TOTAL ACREAGE hiraw f or through his own employees, provided that such improve. menus arc not intended err offered for sale. It, however, the building GAS -EA. SYSTEM - I INC.4 OUTLETS 6.00 orimprovement is sold within one year of completion, the owner- builder will have Ole burden of proving that he did nut build or im- prove 1, aso nee of sale.). ❑ as owner of the property, am exclusively meting with GAS - EA. SYSTEM -OVER 4 (EA.) 2.00 BUILDING USE RES IND CDN PB Omer ❑ ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INrTER. 30.00 , LAWN SPRINKLERS - 1 INC 5 V.B. 6.00 LAWN SPRINKLERS -OVER 5 IEA.) 1.00 ASSESSORS PARCEL NO. d . 70 licensed colons ore to Construct the project La 7044, not ,(I Professions Code: The Contractor's License Law dues not apply tD an owner of property who builAs or improves thereon. and who contracts for such projects with a contractorts) licensed pursuant to the Contractor's License Law, SEWER-SANITARY-STORMEACjW*110.00 O ^ TRACT NO. PARCEL NO. O lam exempt under Sea ,B.&P.C. Iia w.. reason WATER HEATER W/VENT 6.00 owncr Date WATER SYSTEM r 5.00 ACC.DATE ACC. FILE NO. WATER TREATI QUIP. - 5.00 . WORKERS'COMPENSAT10N DECLARATION 1 hereby affirm that I have a certificate of consent to self -insure, or a certificme of Workers' Compensation Insurance, or u certified copy thereof ISec. 3800, Lab.CJ. v Q ` ZONING ENG. SITE NO. NtaP �\ Policy No- Company _ O Ccrtil'icd copy is botchy furnished. k1` C ti i• copy rley.x ul wiflu lh city ire C tion division. Appllcan .'fi ltd1�ji ll r --' FIRE SPRINK V N ❑ ❑ ENERGY T24 Y N ❑ ❑ MISC. - \ REFER TO ORD. CI:R'I'll'ICA'FI-OP IiXlsMpn ON PROM WORKI:RS' PERMIT ISSUANCE 10.00 Q^ FLOOD ZONE A.L.U.C. .CO T ` PLO'^ lao 1704ENSATION INSURANCE 1'fhis section need nut he completed if the Punnit is for ane V N [:J❑ Y N ❑ ❑ QT MECH ICAL PERMIT FEE FEE SUMMARY hundred dTIms(5100)orlessJ r 1 certify that in the p"rmrmdnce of the work for which this nS,- mit is issued, I shall not employ any poison in any manner sn as to BUILDING become suhjcct to the Worker Compensation Laws of California. Dat" Applicant ALTER OR ADD TO MECH. 5.00 NOTICE TO APPLICANT: If. after making this Certificate of Ex- emption, you should become subjcn to the Workers Cnmpenmtioo APPLIANCE 5.00 PLAN CHECK provisions of the Labor Code, you Most forthwith Comply with such provisions or this permit shall be deemed revoked. FEE AIR HANDLING UNIT (TO 10J=C.F.NL) 4.00 AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE CONS'PRUCPION LENDING AGENCY I hereby alTinn Ont there is a construction lending agency fix EXHAUST HOOD (WITH DUCT) 5.00 the performance of the work for which this permit is issued (See. 3097, Civ.C.). HEATING UNIT (TO 100,000 B.T.U.) 8.00 MICROFILM HEATING UNIT (OVER 100,000 B.T.U.)9.50 ELECTRIC Lender's Ne Name Lenders AddNam es< 1 Certify that 1 have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating tO building construction, and VENTILATION FAN (SINGLE) 4.00 PLUMBING oZQ BOILER- H.P. or 100,000 B.T.U.) 6.00 BOILER -COMP IOver 100,000BTUISEE FEESCH. MECHANICAL hereby authorize representatives of this city to enter upon the abuse -mentioned property for inspection purposes. MISC. - REFER TO ORD. (We) agree to save, indunnify and keep hamlcss the City of upertino against liabilities, judgnten s, costs and expenses which may in any way ns said C In consequence of the CONST. TAX PERMIT ISSUANCE 10.00 • un • ul Ibis' I •C� `/� + MELH. CONT. LIC. N0. MECH. __`��„1` `TOTAL W/Contra TOTAL oreofApphctor Date OFFICE COPY • • • s • • • • • • • • • 0 • • • , u_ a s0o a3tlOOW Z S G u w � cx. d w 0 a v v 0 :r s c. CJ �-- u m w s cn s W CL O W 1— F• GJ ' CL' Z Z s- i- w v s is uJ � � v z W a c:l ea e.? r W G_ T W W L1 41 s T s fLi Y-- [IJ 6 Z O W cr l- N ra c � w � -, Uf 2 Y- 4 G u_ a s0o a3tlOOW