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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES,- USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON
APPLICATION & PERMIT
:PERMIT NUMBER
M.'LDING
ADDRESS 7,
D�0 / -T Q TG 6C
(
'
BUILDING
1716 4
OWNER'S
PLAN CHECK VALIDATION
NAME
DTV. ELECTRIC PERMIT FEE
GHONE
I
CONTcToes
NAME
NAME
UTLETS-SWITCHES:RECEP 10.00/1.00
Tan Ppb 5 /he uc. No. 4/%5/6 `/%
J J \V
DATE OF APPLICATION
LIGHTING FIXTURES 10.00/1.00
CONTRACTORS wn TSS
ADDRES%914/NTe�nrnw/ Q✓QPHONEN36-olio
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
ARCHITECT
OR
ENGINEER
LIC. No.
PANELS (OVER 200 AMP) 20.00.
PLAN CHECK FEE D.C. NO.
-
SIGNS TRANS. 1 -3.00
ARCH. ss ENa.
SPECIAL CIRCUIT
5.00
PERMIT VALIDATION
TEMP. METE OR POLE I S
20.00
ZIP
Q' '
APPLICANTS
ADDRESS
MOTORS
SERVICE CHA E
J�GC
LICENSED CONTRACTORS DECLARATION
Is
NNW 1
I hcrchy affiroh flat I mn liccnsad under provisions of Chapter 9
ISSUANCE DATE
(commencing with Section 7000) of Division 3 of the Business and
Professions Code,,an m license is in full mr*Ayd jf ec .7
Licenx•Slaq-(• <b_ Lic. Number!
BLDG.
El
ELECT.
10
PLG. MECH.
❑
T
Dale -5-30 96 Contractor JJJ14_�s_
BUILDING PERMIT
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt GOm the Contractor's License
Law for the following reason. (Sec. 7031,5, Business and professions
Code: Any city or county which requiresa permit toconstru alter,
improve, demolish. Or repair any structure, prior to its issuance, also
requires the applicant for such pentit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
INFORMATION'
MISC. -REFER TO ORD
VALUATION
S/FT.
PERMIT IS ANC 10.00
ELEG CONTR. LIC. NO.
_
ELEC.
TOTAL
PERMIT TO
PLUMBING PERMIT FEE
hu
Law (Chapter 9 (commencing with Section 7000) of Division 3 cifflu,
Business and prolessiuns Cale) or that he is uxem Pt Ilmretrom and OTV.
STORIES
TYPE CONSTR.
the basis for the alleged eacmption. Any violation of Section 7031.5
by any applicant for u permit subjects the applicant to a civil penalty
of not mom than five hundred dollars 15500).):
ALTER -DRAIN -WATER IEA.) 5.00
'
❑ I, as owner of the property, or my employers with wages as
their sole compensation, will do the work, and the structure is not
BACK F LOW PROTECT. DEV ICE 4.00OCC.
GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
and ofessions
intended or offered for sale (See 7044, BusinessPr
Code: The Contractor's License Law does not apply to an owner of
property who builds or unproven thereon. and who does such work
FIXTURES - PER TRAP 5.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
himself or through his own employers, provided that such improve-
mansare not intended oroffered for sale. If. however, the building
GAS - EA. SYSTEM -1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the Owner-ro
builder will have the burden of pving That he did not build or ice
p nlvc for purpose of sale.l'
❑ I, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB ORe�
Q El El Ej C3
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS,- 1 INC 5 V.B. • 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
,
contractors to construct the project (Ste.
licensed Business
On Professions Code: The Contractor's License law dues not apply
to an owner of property who builds or improves thereon. amt who
contracts for such projects with a oontrchadO licensed pursuant to
the Con omtoi s License Law.
SEWER -SAN ITAR V -STORM EA. 200ftI10.00
TRACT NO.
PARCEL NO.
❑ lam exempt under Sea .H.&P.C. tin this
renwor
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC. DATE
AGE. FILE NO. -
WORK ERS' COMPENSA'I'[ON DECLk RATION
WATER TREATING EQUIP. 5.00 k
I her y affirm that I have a certificme of conwrit to self-inmm'ZOrvING
or a cert; bale of Worker; Compensation Insurance, or u certified
ENG. SITE NO.
I copylhurcf(Sec. 3800, Lab. CJ- i/Q �iC04
Policy No. Company /V
❑ Certifcd ropy is hemby furnished
SY Cenifhed��`��`((((((oppppppy is t4•�ith-{he city inspection division.
pplmant_Gl.� (
FIRE SPRINK
Y N
ENERGY T 24
V N
MISC.- REFER. TO ORD.
L CERTIFICATE OF 17XEM'19 ION FROM WORKERS'
PERMIT ISSUANCE 18-00 2Q1
FLOOD ZONE
A. L.U.C.
PLG. CONTR. LIC. NO.
! rT n / 'HCy v6�7
PLG. r ('}'�
TOTAL / Vjl7/
COMPI'NSATION INSURANCE
1 IT his section need nut be conplrtrd if the permit is for one
hundred dollefs(SI00).,I..)
1 certify that in the performance of the work for which this per-
mit is issued, I shall not empWy any person in any manner so as to
beconm subject to the Workers' COnhpunsaImn Laws of California.
[)areApplicantALTER
NOl'ICE TO APPLICANT: If, after making this Certificate of Ex-
Y ❑ N❑
Y N�
-
OTYMECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
. .
OR ADD TO MECH. 500
APPLIANCE 5.00
PLAN CHECK
emption, you should become subject to the Workers' Compensation
Provisions of the Labor Code, you must forthwith comply with
' such .H,.r this permit shall he deencd evoked.'
FEE
AIR HANDLING UNIT (TO 10)"C.F.MU 4.00
AIR HANDLING UNIT(OVER 110 OWC.F.M.) 6.00
SEISMIC FEE
CONST RUCTION LENDING AG17NCY
I hereby affirm that there is a construction lauding agency for
EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this Ninth is issued (Sec.
3097, Civ.C.).
MICROFILM
HEATING UNIT (TO 1D0,D00 B.T.U.) 8.00
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
Lenders Name
Lender's Address
1 certify that 1 have read this application and sew that the above
nfnnnmlon P, correct. I agree to comply with all city and county
Ordinances and state laws. relating In building construction, and
VENTILATION FAN (SINGLE) 4.00
PLUMBING
�.
BOILEA-COteP (3 H. P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 10,000 BTU) SEE FEE SCH.
MECHANICAL
hrrtby mthurize representatives of the city to enter upon the
above-mentioned property for inspection purlwses.
MISC. - REFER TO ORD.
(We) agree to save, indemnify and keep hmmlts the City of
upertino against liabilities, judgments, costs and expenses which
ay in any way accrue against said City in consequence of the
CONST. TAX
PERMIT ISSUANCE 10.00
MECH. CONT. LIC. N0.
MECH:
OTAL
TOTAL
&�
olio of this prrmil.
--30-510
Signature ofA lioam/=Contractor Der
OFFICE COPY