C8638 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATION PERMIr NumeER
ADDRESS APPLICATION & PERMIT 8638
Bo LDIN
p Ilk BUILDING-ELECTRICAL-PLUMBING -MECHANICAL rvE 5 PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE
• orvE
rvAWI (/[� OUTLETS-SWITCHES-RECEP 10.00/1.00
V
/N /(yO�j7c.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS '
Y / ' 1/ PANELS 10.00 DATE OF APPLICATION
ORRCRITECi PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG SPECIALCIRCUIT $,0.Q PERMIT VALIDATION
_ ZIP EMP.METER OR POLE INS. 20.00
APPLICANT'S -� r MOTORS SEE FEE SCH.
ADDRESS
• ' - ' SERVICE CHANGE 20.00
wooF LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
¢ it tj ( 1 hereby affirm that I um licensed under provisions o'Chapter 9 ISSUANCE DATE
a 4 "' (commencing with Section 7000)of Division 3 of the Business and -BLD ELECT. PLG- MECH.
N i Professions Code--,and__n}y license i,in full fo •un 4'ct
z o m - License ClassLh�Lin.Number
Pm nw // '�Contmctnr
��` a -� BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION ��
o a" MISC.- REFER TO ORD INFORMATION
X
3 u y I hereby oollo that 1 not exempt loom the Business
d Pro fess, is VALUATION
FLLo J Law for the following reason.(Sec.703 t.5,BusinessunJ l'rol'essions PERMIT ISSUANCE 10.00 $iFT.
mN Code:Any city orcounty which requires a permit 10 construct,alter,
¢ a> 2 ELEC.CONTR. LIC.NO. 1
a o improve,demolish,or repair any structure,prior to its issuance.also ELEC. / )
¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n w revshe is licensed pursuant to the provisions of the Contractor's License
HzLaw(Chapter9(commencing with Section 7000)o'Division 3 ofthe U
i o ,Business and Professions Code)or that he is exempt lhemfrnm and QTY. PLUMBING PERMIT FEE
It H m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
ate _ by any applicant ter apermit subjects the applicant toacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,as'owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 OCG GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered lilt sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:I'lie Contractor's License Law docs not apply to an owner of
property who builds or Improves thereon,and who does such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-11NC.40UTLETS 6.00
ments are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS EA.SYSTEM OVER 4 (EA.) 2.00
builder will have the battler of proving that h - -
e did not build or int- - BURRING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RS IND CON PB Omer
. .
❑ I,as owner of the Property,ant 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 License 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")licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
❑ I and exempt under Sec. ,B&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 55.00 ACC.DATE ACC.FILE NO.
/ WORKERS'CONIPENSATION DFCLARA'NON WATER TREATING EQUIP. ;5.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING or a certificate of Workers'Compensate Insurance,or a certified ENG.SITE NO.
copy I No. (Sec.3800,Lab.C.).S��G
Policy No. Ca hereby
y' 7
❑ Cetlil ied copy is Itireby furnished. FIRE SPRINK ENERGY T 24
Z Z 0 Centric y is le ith th c'ty ins action drci on. MISC.- REFER TO ORD.
O APPlicanP / � Y❑ No , Y ❑ N❑
cc: y CIiR 'l l'ICA'(i Oft hXIi MPTION[ OM If KERS' PERMIT ISSUANCE 10.00 FLOOD ZONE a.L.U.C.
LU > COMPFNSAI'ION INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ N❑ Y E) N❑
Z (This section need noOTA
t be completed if the permit is for one T
hundred dollars(5100)or less.)
U O I certify that in the performance of the work for which this per- OTY. t MECHANICAL PERMIT FEE FEE SUMMARY
LL F Coif is issued,I shall not employ any person in any manner so as to
Ow become subject to the Workers'Compensation Laws of Qdifornia.
a Dalo ApPli"tot "- �" ALTER OR ADD TO MECH. 5.01) BUILDING 0
>_ W NONCE TO APPLICANT: If,after making To,Certificate of Ex-
F. ? emption,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
I
coNs'I'RUCI'10N LENDING AGENCY AIR HANDLING UNIT(OVER I0,OODGEM.16.00 SEISMIC FEE
1 hereby ullino that Iheru is a colutn¢i10n lending agency for EXHAUST HOOD(WITH DUCT) 5.00 `
the performance of the work for which this permit is issued(Sec. MICROFILM J
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Addr HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC -
1 certify that I have read this application and state that the above - NTILATION FAN (SINGLE) 4.00
r ® in herniation is correct. I agree to centply with 311 City and County PLUMBING
it
and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) '6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cuperitino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10,00 CONST.TAX
may t any way accme •roost said City in consequence of the
n gran D"this poet. �. CH.CONT. LIC.NO. MECH. q
„y 7 TOTAL / TOTAL I� "10
oat e A pl c nt/ ontractor Date .10
INSPECTOR COPY j r
r
f