2892 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENT[FICATION - R UMBER
BUILDING 'APPLICATION & PERMIT 8(�
OsDOREss s
i �„ ""
� BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
OTY. ELECTRIC PERMIT FEE
CONTRACTOR
NAME UTLETS-SWITCHES-RECEP 5.00/1,00
ACE UC.No. - LIGHTING FIXTURES 5.00/1.00
r,ONTVWMBING SERVICE PPLIANCES-RESIDENTIAL 4.00 -
ADOR
PHONE PANELS 5,00 DATE OF APPLICATION
"R SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGtrsy�N -JOSE: CA 9 O
L1[.Ird SIGNS TRANS. 3.00
ARCH.OR EN SDD PERMIT VALIDATION
ADDRESS 4408) 297- 107 SPECIAL CIRCUIT
ZIP TEMP. METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
� woo LICENSED CONTRACTORS DECLARATION
Q v 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
as a w (Commencing with Section 7000)of Division 3 of the Business anJ
F i Professioty:�0 my license is in full fgrlggyL`el}CIY�-1 RLUG. ELECT. PLG. MECH.
zO= License C�-` Lic.Numby�l
4 T F w Dale Contractor
vc f BUILDING PERMIT
¢ ¢w ¢ OWNER-BUILDER DECLARATION INFORMATION
R 0a " MISC.- REFER TO ORD
X 3: N I hereby affirm that I am exempt from the Contractor's License VALUATION
U. Law for the following reason(Sec.7071.5,Business Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,alter,
ce ¢ ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
ou
S 0M requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's License �1
H z i Law(Chapter 9(commencing with Section 7000)of Division 3 of the l.�L.g �-
a Business and Professions Code)or that he is exempt therefrom and QTY, PLUMBING PERMIT FEE I
CE = the basis for the alleged exemption.Any violation of Svcti6n703I.5 STORIES TYPE CONSTR.
uby any applicant fora permit subjects the applicant ton civil penalty gLTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole Compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,CON D. 4.00
Code:'floe Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.60 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended oroffered for sele.If,however,the building GAS-EA.SYSTEM-l1NC.4OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 (EA.) 100 BUILDING USE
builder will have the burden of proving that h . . .
e did not build or im- RES IND CON PB Orher
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the Project(See,7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does'nol 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(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ lam exempt under Sec.-.R.&P.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK E RS'COMPENSATION DECLARATION IWATER TREATING EQUIP. 4.00
I hereby affirm that I have a Certificate of consent to self-inuuc, ZONING ENG.SITE NO.
or a certificate of Workers'Cum easatio I umnce,or are Ified
P
�y/ t1 "b.C.)��ec�eI�
Q any
Certified copy is lereby furnished. - FIRE SPRINK ENERGY T24
Z Z Certifie Py 's fled +titb I 'ty 'ns ection division. MISC.- REFER TO ORD.
O ApplicantY ❑ N❑ Y ❑ N[]
CC !Ay -PERMIT ISSUANCE, 6.00 FLOOD ZONE A.L.l1.C.
- CERTIFICATEOF IiX1iMPTION FR RF:ERS'
11J 1 COMPENSATION INSURA AMOIE
PLG.CONTE. LIC.NO. PLG.
CL a (This section need not be completed if the Permit is for one IT TA I Y❑ N❑ Y ❑ N❑
2 hundred dollars is 100)or less.)
U O I Certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
C) do Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} rail NOTICE TO APPLICANT: If,after making this Certificate of Ex-
(_ Z emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=11F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ.C.).
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
Information is correct I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby aulhorite representatives of this city to enter upon the BOI LER-COMP (Over 100,009 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cu ertino against liabilities,judgments, costs and expenses which CONST.TAX
Kra. h on way true againstconsequence of the PERMIT ISSUANCE 3.00
gran ng this er iL MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
oat re o Pplicanl/Coatorc
OFFICE COPY