7119 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BAL14POINT PEN ONLY
BUILDING PROJECT I DENTI FICA710N
PERMIT NUMBER
RUILDING'`, APPLICATION & PERMIT 71. 19
ADDRESS l
1 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OwNPLAN CHECK VALIDATION
' L- T ELECTRIC PERMIT FEE
• 1i P/0 ON
CONTRA T OUTLETS-SWITCHES-RECEP 5.00/1.00
c.No LIGHTING FIXTURES 5.00/1.00
DRESSelq PLIANCES-RESIDENTIAL 4.00
,} � ( NE ANELS 5.00 DATE OF APPLICATION
A.r,• ARCHITEF SIGNS 6.00 PLAN CHECK FEE p.C.NO.
$ OR
Ir ENGINEER
LIC.No, SIGNS TRANS. 3.00
ADD Ess ENG. PERMIT CIRCUIT 5.0Q PERMIT VALIDATION
.''
ZIP ITEMP.METER OR POLE INS. 15.00 `
AMOTORS SEE FEE SCH. JC
DRESS E55
ADDR
SERVICE CHANGE 10.00
orct.
LICENSE U CONTRACTORS DIiCLARATION
rt U w I hereby allirm Ilial I con licensed under provisions of Chapter 9 ISSUANCE DATE
t- G k (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F 4 i)j Professions Code,and my license is in full force J ❑ ❑ ❑ ❑
z o -?liby
License Cl Lie Number
F�'. Du1Contracfor
- J'.
¢ y f BUILDING PERMIT
Ix at 4 OW LDHR DECLARA' 1
O
U. MISC.- REFER TO ORD INFORMATION
w g LL y I hereby affirm that I am exempt from the Contractors License VALUATION S/FT.
v- LL o ¢ Law for the following reason.(Sec 7031.5.Business anA Professions PERMIT ISSUANCE 6.00
w 0 Code:Any city or county which re9uiresa pernin to CmoO.cL atter,
improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. -
Ov, relluires the applicant Our SUCK permit to file a sigma statement that TOTAL PERMIT TO
w ce uihe is licensed pursuant to the provisions of the Contractor's License
H z vL' Law(Chapter 9(commencing with Section 7000WI'Division3ofthe �L G
®�GBusiness and Professions Code)of that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
the basis forthealleged exemption.Any'violation ofSCCtioD 7031.5 STORIES TYPE CONSTR.
m any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER MA.) 4.00
of not more titan five hundred dollars(5500).):
❑ 1,as owner of the property.or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
-%� Ihmf sole compensation,will do the work,and the stmcmre Is not
intended or offered for sale fSec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
• Code:The Contractor's License Law docs Col apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsareGot int.oed or offered for sale.If,however.lire building GAS-EA.SYSTEM=19 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner-
buiWer will have the burden of proving that he did not build or im-
prove for purpose of sille.l. INDUSTRIAL WASTE INTER. 20.00 0 El El El 0
� ❑ I,as owner of the pro,I am exclusive)
C4 P tr Y. ycontracting 7044, usineh
licenced contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
L " 'It, rt ,wC,r ,it properCode y vvlionbuild,tractor's, License Law,th does Cut apply
E In tr owner of property who builds lr improves Ihcica aand who LAWN SPRINKLERS OVER 5(EA.) 1.00
l;4 =
contracts ruck for such projects with a contmelorl s)licensed pursumnl to
the Contractor's License Law. SEWER-SANITAR V-STORM EA.200ft/8.00 TRACT NO. PARCEL No.
t ❑ I am exempt under See ,E14P.C.for tills WATER HEATER W/VENT4.00
rcamn
D
Owner ale WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
°*,' WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
? I hereby al(irm Than I have a certificate of consent to self-insure.
nr a Certificate of Worked Compensation h suranee or a certified ZONING ENG.SITE NO.
copy 11 .{ �yjaK.,
n, � �ygQf c j
1 1'uliEl " I� IAh,�i-
A ❑ Cern is c'o [hereby')utQlsle FIRE SPR INK ENERGY T 24
Z Z s O Cer ed • is fie Ili• ci - sptiv io' MISC.- REFER TO ORD.
O ,\pplicanl _ Y NY ❑ NE]
PERMIT ISSUANCE 6.00 PLOODZONE A.L.U.C.
- CF IPIG\TE OPF,XBMPTINSPROM WORKERS'
LU > need not
be comIONpleted
INSURANCE PLG.CONTR. LIC.N0. PILO Y N Y � N
a O1'This •Coon need not he completed i(the pennil is for one TOTAL 1
Z EI
hundred dollars(5 100)or less,)
U O 1 certify that In the performance of the work for which this per, OTY. MECHANICAL PERMIT FEE FEE SUMMARY
L trimmer P a Cot is issued,I shall nor employ any person in any trmer soas it)
O.,L) Neomcsubject m tits WOrkefSCOmpe'RYatlDO laws of CaGoow.UJ BUILDING �
.D, Ualc .lpplicant ALTER OR ADD TO MECH. 4.00
}'tn. NOTICE TO APPLICANT: If,after making OuS Certificate of Ex-
F:Z( eruption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
1, - provisions of the Labor Code, you must forthwith comply with FEE
0y t1: such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT ITO 10=C.F.M.) 3.00
'k AIR HANDLING UNIT(OVER 10=C.F.M.15.00 SEISMIC FEE
CONS RUCTION LENDING AOI:NCY
a - I hereby affirm than there is a c st lion lending agency for EXHAUST HOOD(WITH DUCT) 2.00
S +I the performance of Ihu work f which this
d pnrnn Is issued(Set. MICROFILM
` 3097, Nal. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's,',Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lenders Address ELECTRIC
I certify that l have read thisapplicaliun and state that the above VENTILATION FAN (SINGLE) 3.00 l
01 o information is correct. I agree to comply with all city and County PLUMBING
N
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
• hereby autimrme representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
L above-mentioned property for inspection purposes,
\ (We) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
". ffupertino against linhililies,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
ma in any way ace a against said City in con quence of tis
g iog of this Pc m CONT. LIC.NO. MECH.
TOTAL TOTAL
lure of Applicant/Contractor 7 Dale t
INSPECTOR COPY