6559 APPLICANT TO,FILL IN INFORMATION WITHIN.RED LINES,- USE BALLPOINT PEN ONLY
PERMIT NUMBER
BUILDING PROJECT IDENTIFICATION
BUILDING' .APPLICATION &PERMIT
nooREss
6559
BUILDING—ELECTRICAL—PLUMBING—MkCHANICAL
Ir
V,.
OWNER'$ • - --' -- - _ PLAN CHECK VALIDATION
} NAME . l OTY. ELECTRIC PERMIT FEE O
PRONE
CONTRACTOR
NAME UTLETS-SWITCHES-RECEP 5.00/1.00
sec.No. LIGHTING FIXTURES 5:00/1.00 ` `` �,� VIV
ei
1 f.NTRACTo.' APPLIANCES-RESIDENTIAL 4.00 Jv, CVQQ
ADDRESS , .. .. .• - t �xis
PHONE PANELS 5.00 DATE 11ICArlory
ARCHITECT,
SIGNS ' 6.00 PLAN CHE E P.C.NO.
OR -
' ENGINEER , -
LIC.No. SIGNS TRANS. - •3:00
AnCH.OR ENG. r - - PERMIT VALIDATION
Aooness • ` SPECIAL CIRCUIT -5.00 •-q;
ZIP EMP.METER OR POLE INS.
APPLICANT _ MOTORS + "" SEE FEE SCH. s
'
ADDRESS S
ADDn ' I
SERVICE CHANGE - 10.00 �l .
ort z T'02
LICGNSEU CONTRACTORS DECLARATION 1 I'-O S' '
u'H I hereby A(lirm that I am IixnseA undor provisions of Chapter 9 (p—.I ISS ANCE'DATE
,HA a y' [commencing with Section 7000)of Division 3 of lire Bu>inss and - BK ELECT. ^PLG. MECH.
H H Z, Pmfessions Code,and my license is in full foSe'and effect "' r - �e _❑ ❑
Z o m License Class Lic.Number -
Z H w )ateContractor I`, .
a y f - i BUILDING PERMIT
a a o OWNER-RUILDER DECLARATION - _. ' INFORMATION
wg u I- I hereby.Alror that I am exempt from the Contractor's License MISC:— REFER TO ORD y UATION
F u o¢ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00 $jFT
Code:Any city orcounty which requiresa permit to construct,alter, - -- - -
' BS ¢¢0 improve,demolish,or repair any structure,prior to its issuance,Also ELEC.CONTR: y p LIC.,NO. ELEC.
a wo,mL requires the applicant for such permit to file a signed statement that TOTAL' PERMIT TO
0 he is licensed Pursuant m the provisions of the Cootracto�,License- _
H Z i
Law(Chapter9(commencingwith Section 7000}nf Division3ofthe -
a Business and I'mfecibms Code)or that he iscxanpt therefrom and DTV. - PLUMBING PERMIT FEE
rt.r Oo lire basis for the alleged exemption.Any violation of-Section 7031.5 STORIES TYPE CONSTR.'
"d-;m by any npplid5ntCoru permit subjects lhcigtPliwnt ldacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00r+ ' 1 '�
if not mom
titan five hundred dollars(85001.): w ' ^ • i ,
❑ 1,as owner.1 tire property,ar my employees with wagosas 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,AREA,COND. 4.00 ' all
Cade:The Contractor's License Law dos not apply to an owner of '
Property who build%or improves thereon,and who doessoclt Work FIXTURES-PER TRAP , 4.00 SO.FT.FLOOR ARE TOTAL ACREAGE
himself or through his own employees,provided that such improve. .
ments a in nut intended or offered for sale.If,howevegthe building GAS-EA.SYSTEM:'1INC:4 OUTLETS 4.00 '_
or improventent'is sold within one year of completion,the owner. GAS-EA. -OVER 4 IEA-.)
'builder will have the burden of proving that he did Hot build or int- : ' 1.00 . BUILDING USE .
prove for purpose of sale.). INDUSTRIAL'WASTE INTER. 2000 E '.IND CON PB Other
❑ I,as owner nl the property,am exclusively contracting with . ❑ .❑ ❑ ❑
- licensed contractors In conslrlicl'the proper(See.'7044,11usiness LAWN SPRINKLERS-ZINC 5 V.B: ' ' 5.00 .. ASSESSORS PARCEL No.
and Professions Code:The Contractor's License Law does not apply - -
lO an nor of Property who builds or lnlproves thereaR.-and who LAWN SPRINKLERS-OVER 5(EA.) _1,00 i +
ams cls I'or.cuch projects with a contractorts)licensed pursuant to +
'ammctors License.Law. - SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
I am exempt under sec._ ,B.&P.C.for it, WATER HEATER W/VENT 4.00
O= Darr._tj! -- WATER SYSTEM - 4.00 ACC.DATE ACC.FILE NO.
WORKS RS'COM PENSAT'ION DECLARATION • WATER TREATING EQUIP. - 4.00 -
\ s ,.I hereby affirm that I have a certificate nfronsenl to self-insure, - ZONING
10 ar a certificate of Workers'CmnPenution Insurance,ora certified ENG.SITE NO.
/ copy thereof(Sec:3800:I.A.C.). -
' ' Policy No. Company
O ❑ Cc ifictl[opy.is hereby faEl$hcd.' T FIRESPRINK ' ENERGY T24
z Z .❑ Cerlifie.d copy is filed with the.city i....pectidli Division. MISC.- REFER'TO ORD, t
O APPlicant - - Y ❑ N❑ Y-❑ . No
F m •PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.c.
LU ,CIi R'I'I PICA'fli OP EWIO fINSURA M WORK CRS' .
LL .COMPENSATION INSURANCE PLG.CONTR.,), „ 'LIC.No: PLG,.. ,
Z) O LI his sectic.. need not be completed if the Permit is for one TOTAL V❑' N❑ Y❑ N❑
2 'hundred dollars($100)or lcsa) y's ` -
U.O , I certify that in the performance of the work fol which Ibis per, OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued,1 shall not employ any person in any manner so as to
U becamesubject to the Workers;Contpensalion Laws of California.
DD Date APpbcaia - ALTER OR ADD TO MECH. 4.00 BUILDING
} m NOTICE TO APPLICANT: If,after making this Certificate of li x.
F ? 'cmplion,.you should become subject to.the Workers'Compensation APPLIANCE _ 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply'wiih FEE
U such provisions or this permit shall he deemed revoked AIR HANDLING UNIT(TO 10MC.F.M.) 3.00 '
CONIS7'RUCTIONLENDINCAGGNCV AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE .r
]'hereby affirm thut'tbere is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
[lie perfoonunce of tire work for which this permit is issued'(Sec. - MICROFILM
3097,Civ.C.). _ - HEATING UNIT(T0100,000 B.T.U.) '4.00
Lender's Name HEATING UNIT(OVER 100,0 . . .
00 BTU)7.50
Lender's Address ELECTRIC
I certify that l 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. PLUMBING
ordinances and state laws relating to,building construction, and BOILER-OOMP(3 H.P.or.100,000 B.T.U.1 4.00
hereby authorize representatives of this city Io.enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspectionymposes.
(We) agree to suve,'indemnify and k.C,.harnrless the City oI " MISC:1 . n REFER TO ORD. _
Cuperlino'againsr liabilities,judgments, costs and expenses which - CONST.TAX
may in any way accrue against Said City in consequence of the PERMIT ISSUANCE 3.00
V granting Of this permLLMECH.CONT :+ c LIC.NO, MECH.
TOTAL TOTAL
&gnalurc of Apphcnn[jContmctor )ate— '• '�
OFFICE COPY-,; -