7108 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT-1PERMIT NUMBERBUILDING DENTI FICATION -APPLICATION & PERMIT
AOOREss. - 887
Il" \ � BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
NER's/I ! J PLAN CHECK VALIDATION
NAME ` OTY. ELECTRIC PERMIT FEE
. PHONE -3_17- YJ .
NANTA T RS UTLETS-SWITCHES-RECEP 5.00/1.00 /
LIGHTING FIXTURES 5.00/1.00 /
NO.
CDNT Tons PPLIANCES-RESIDENTIAL 4.00 /
tARCHITECT
ORE s
C PHONE - PAN ELS 5.00 DATE OF APPLICATION
SIGNS 6.00 PLAN CHECK FEE P.C.NO.
�9GINEER sec.No. FjSIGNS TRANS. - 3.00
C iss EN SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
- G zm TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS �1
N r SERVICE CHANGE 10.00
0 0 o LICENSED CON FRAC DECLARATION - 7
td, u I hcrcby affum that I am licensed under provisions of Chapter 9 ISSUANCE DATE
' H G a (commencing w' •[lion 1000)of Division 3 OI the Business and - BLDG. ELECT. PLG. MECO:]
F H iProfessions Cod my license is in full for an fife L
Z tf
o m - 'Licmvse Class I.ic.Number- / IWMI
'0�� H D Daly Contractor {„ /
¢ry E Z £1+ 4 t BUILDING PERMIT
XXi:
K w a NISR-BUILDER DEC A I N INFORMATION
oALI MISC.- REFER TO ORD
i: LL r I hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
IHuo J Law for the following rcasoo.(Sec.70715,Businessund Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,alter, 1'�f Ono
-�Q K¢ O improve•demolish,or repair any slnmture,prior to its issuance,also ELEC.CONTR.
LIC.NO. ELEC. 1
.D u requires the applicant for such permit to lite a signed statement that ' TOTAL ' / PERMIT TO
wm-, he is licensed pursuant to the provisions of the Contractor's License
tH z a
Law(Chapter 9(commencing with Section 7000)o f Division 3 fthe
4 D Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE Pv
H mthe basis for the alleged exemption.Any v101ulNfo oSection 7031.5 STORIES TYPE CONSTR.
by any appheantor a permit subjects the applicant ua civil Penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of lint more than five hundred dollars($500).).
0;1,as Owner of the property,lir my employees with wakes as BACK F LOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and lite structure Is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 'Tj(l
Code:The Contractor's License law docs not apply to an owner of
property who builds or improves lllcrcon,and who does such work FIXTURES-PER TRAP 4.00 / 50.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve- / \-'.'d
mems arc not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00 / v
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00
builder will have the burden o'prosmg,that he did not build or im USE
E IND BUILDING NG PB OtM1er
prove for purpose of sale .). INDUSTRIAL WASTE INTER. 20.00
+. ❑ 1,as owner of the property,um exclusively contracting with ❑ ❑ ❑ 11licensed contractors to construct the project(See. 7044.Busine,vs LAWN SPRINKLERS-1 INC 5 V.B. 5.00 CCS, ASSESSORS PARCEL NO.
and I'oessions Code:'I'li. to
Contracrs License Low docs not apply
to an owner of properly 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
the Contmaar's License Law. SEWER;SANITARY-STORM EA.200ft/8.00 -8,� TRACT NO. PARCEL NO.
L❑ nl not exempt under Sec.-,B,&P.C.far Ihii WATER HEATER W/VENT 4.00 - /
Owner Date WATER SYSTEM 4.00 ---T%-cc.DATE ACC.FILENO.
r ;
\a�pppp R//k.,",/��gS�'f77fONPI' SA'I'ION DECLARATION WATER TREATING EQUIP. 4.00
1, If �ficate of[novena lO self-insure' ZONING
or a cerliticme of Worked Compensation Insurance,or a certifies! ENG.SITE NO.
copy lhereof(Sca 3900Lb C.l /�(� /
Policy No. Co;mpany- /\L
' O ❑ Certified copy is hereby funtolted. FIRE SPRINK ENERGY T"24
Z'2 `ty.CertilglL+s is file with the city inspection division. MISC.-/vREFER TO RD. ❑ ❑ ❑ ❑
U A licent T) 4 C/ A/ � i Y N V N
CC T PERMI .ISSUANCE -' �'' X6.00 t / FLOOD ZONE A.L.u.c.
Lr . C-IiR1'IPICA"Ili 0!'Ii XEMF`p ON PROM WORKERS' _
W > COMPENSATION I NSURANCE PLG.CONTE. LIC.NO. PLG. /
4. o ('Phis section need not be completed if the Permit is for one TOTAL Y❑ H❑ Y ❑ N❑
D 2 hundred dollars(S100)or le..)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL !- 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.
ED Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} rn NO'1'ICF.-TO APPLICANT: If,after making this Certificate of I?x- t
F 2 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
L) such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10=CF.M.) 3.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the pertorinance of the work for which this permit is os ed IScc. / MICROFILM /
30971N.0 T L174HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name H EATI N G UN IT(OVER 100,000 B.T.U.)7.50
Lender's Address- ELECTRIC
I certify that l!lave rad tfiis uhpllcaD> �il�slite lbm lite above VENTILATION FAN (SINGLE) 3.00 /
• infommtion is correct.1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (0.,100,000 BTU)SEE FEE SCH. MECHANICAL
above mentioned property for inspection purposes.
(We) agree to save, indemnify and keep hornless the City of MISC.- REFER TO ORD. /,(////.9
Cuperlino against liabilities,juogntents, costs:cod experees which CONST.TAX - / 1 /
ntxy in any way accrue air us said City in cunsequence of the PERMIT ISSUANCE 3.00 1
granHr*-9,f-N(spermit. MECH.CONT. LIC.NO. MECH.
21 TOTALI / TOTAL
Sigwture of Appli lint/ ontractor ale 4
INSPECTOR COPY - -