C8707 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENT(FICATI PERMIT NUMBER
ButAPPLICATION & PE R
o rvc w 0 7
BUILDING - ELECTRICAL-PLUMBING-MECHANICA 8707
OWNER'S PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE /
-7? /n•{..�Q
ONE J ATORSNAME OUTLETS-SWITCHES-RECEP 10.00/1.00LIGHTING FIXTURES 10.00/1.00T ADDRESS PPLIANCES-RESIDENTIAL 4.00L�KL OrvE 377 PANELS IO.00 DATEDLICATION
OR A T PANELS (OVER 200 AMP) - 20.00 PLAN CHECK FEE P.C.NO.
' ENGINEER
Llc,No. SIGNS TRANS. 3.00
AARCH.OR DDRESS EN f SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
f ZIP EMP.METER OR POLE INS. 20.00
ADDDREDRESSS ,t
ASMOTORS SEE FEE SCH.
i SERVICE CHANGE 20.00 !�
at o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a 0'v 1 hereby uffinn that I am licensed under provisions of Chapter 9 ISSUANCE DATE
N z y (commencingwill,Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H N i Profession,Code,and my license is in full force and effect. ❑ El Elb:z o - License Class Lic.Number
F m o 'pate ntractor
BUILDING PERMIT
',�•. d a w a OWNER-BUILDER DIiCLA�i17J((MM•t T INFORMATION
r oa " MISC.- REFER TO ORD
X ; LL I hereby uffinn that I um exempt from the Contramoi s License
ic0< I.aw for the following rcasou.(Sec.7031.5,Businasand Professions PERMIT ISSUANCE 10.00 VALUATION
S/FT.
w v, Code.Any city or county which requires permit to construct,alle', - // �y�O
e, ca 0 improve,denmlish,Or repair any structure,Prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
ou E 0 u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n m he is licensed Pursuaol to the provisions of the Contractor's License
U,
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
Business and Professions Code)or that he is exempt therefrom and UMBING PERMIT FEE DA r
DTV. PL4
o the basis for the alleged exemption.Any violation of$ection 7031.$ STORIES TYPE CONSTR.
by any applicant for it permit subjects the opplieuntto a civil penally ALTER-DRAIN&VENT-WATER (EA.) 5.00
Of not more than five hundred dollar,(5500).1:
❑ I,as Owner of the property,or my employees will'wages` BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale(See 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
r ments are not intended or offered for sale.If.however.the building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is Sold within one year of completion,the owner GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or int BUILDING USE
prove for purpose of Nde). INDUSTRIAL WASTE INTER3000 RES IND CON PB o,her
❑ I,as owner of the property,um exclusively contracting with . .
❑ ❑ ❑ ❑ ❑
licensed contractor, to construct life project(See 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 x ASSESSORS PARCEL NO.
and Professions Cod'c:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPR INKLERS-OVER 5 (EA.) 1.00
,.atmos for such projects with a connuctods)licensed pursuant to
the Contractor,License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sar.-,BAP.C.for this WATER HEATER W/VENT 6.00
on
Owner Dale WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO.
WONKERYCONiNSATION DECLARATION WATER TREATING EQUIP. 5.00
M
1 hereby uffinn that I have a certificate of conscut to self-insum,
or a certificate of Workers'Compensation Insurance,nr a certified
ZONING ENG_SITE N0.
7 copy thereof(See,3800,Lab.CJ. '
Q ❑ Certified copy is hereby ural FIRESPRINK ENERGY T 24
Z Z�. ❑ CertifiJd co fed the city iJ�specoon division. ` MISC.- REFER TO ORD.
O APpllnant //� i� .�2C Y❑ N❑ Y ❑ N❑
N w -� ✓ PERMIT ISSUANCE 10.00
LU - CHRTIFICCOM E SAT( N INS FROM WORKERS FLOOD 20rvE A.L.U.C.
LL COMPENSATION INSURANCE:. PLG.CONTR. LIC.NO. PLG.
} D fifths section need not be completed it'the permit is for one TOTAL ' v❑ N❑ V E] NE]
dollar,($100)or less)
U O 1 certify that in the performance of the work for which this per. CITY. MECHANICAL PERMIT FEE. FEE SUMMARY
1L 1- mil is issued,1 shall not employ any person in any manner so as to
Ow become subject to the Workers Compensation laws of California. BUILDING
D- Date Applicant ALTER OR ADD TO MECH. 5.00 -
N NOTICE TO APPLICANT: If,after making this Certificate of Ex- -�
2 emplion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
tiprovisions of the Labor Code, you must forthwith comply with FEE
y Usuch provisions or Dlis permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 4.00
_
CONS]'RUC'IIONLENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE �zO
I hereby affirm that there is a construction lending agency for I EXHAUST HOOD(WITH DUCT) 5.00
Dlelperformance of the work for which this permit is issued(Sec. MICROFILM
3097.Civ,C.), HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's,Add Name 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 VENTILATION FAN (SINGLE) 4.00
it is correct. I agree to comply with all city and county PLUMBING
'r ooliminces and state laws relining to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby rothoriee representatives of thiscityto enter upon the BOILER-COMP (Over 100,000 BTU(SEE FEE SCH. MECHANICAL
.� above-mentioned property for inspection purposes.
Is (we) agree In smx, indeml ify and keep harmless the City of MISC.- REFER TO ORD.
Cuperlino against 'abilities,j,gments, costs and expenses which CONST.TAX
m' in an we
c agai t 'ty in consequence of the PERMIT ISSUANCE 10.00
gr' ting of his ria / MECH.CONT. LIG NO. TOTAL o
Si a r fAppli 1 TOTAL
INSPECTOR COPY T�