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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BVI LOI NG PROJECT I DENTI FICATION
aDiLDiNG APPLICATN &PERMIT
POORE
BUILDING — ELECTtIU
MBING — MECHANICAL
PERMIT NUMBER
OWNER
E
AN CHECK VALIDATION
ONE �
�NAME O UTLETSSWIEP 5.00/1.00uc.
No,
LIGHTING FIX T5.00/1.00f.ONTflACiOR'SADDRESS
PPLIANCES- RL 4.00
PHONE
APCHITECT
DATE OF APPLICATION
PANELS 5.00 a
ENGINEER
SIGNS 6
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3,00
AENGua. NO.
.
ADDRESS oPEss
� SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
Zip
TEMP. METER OR POLE INS. 15.00
APPLICANTS
ADDRESS
OREss
MOTORS EE FEE SCH.
SE'- CHANGE
RVICE "" 10.00)-i'//
ISSUANCE DATE
INCENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9
f commencing with Section 7000) of Division 3 of the Businessand
Professions Code, and my license is in full force and effect.
License Class Lic.Number
Date Con Cont radar
APR
SLD EW. -- PL MECH.
OWNER -BUILDER DECLARATION
I hereby alfirm that I am exempt from the Contractor's License
Law for the fu Mowing reason7031.5, Business and Professions
Code : Any cityor countywh 'ch req vires a Permit to con struct alter,
improve, demolish, or repairany Structure , prior to its issuance, also
requires the applicant for such permit 10 file a signed a.lemtnl Thar'
he is licensed pursuant [o [he provisions O( the Can ! -clot s LlCense
Law(Chapter9(Commenciag with Section 7000) of Division3o(Ihe
Business and Professions Code) or that he is exempt Therefrom and
the basis for the alleged exemption. Any violation of Section 7031.$IFS
by any applicant for a permit subjects heapplies- loo civil penally
of not more than five hundred dollars IS5W),I
❑ e' as owner of the property, or my employees with wage as
I heir sole compensation, will (S the work, and the s[mcturc is not
I
oil Ted or offered for sale (Sec. 7044, Business and Pro(nsions
Code: The Contractors License Law don not apply to an owner Of
properly who builds Or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
meats are not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im-
Prove for purpose of sale.).
P I, as owner of the properly, am exclusively Contracting with
rs
contracto[O Construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Low does not apply
to an owner of property who builds or improves thereon, and who
contracts for such projects with a contractolls) licensed pursuant to
the Contractors License Law.
❑ 1 am exempt u der Sec , B.&P.C. for this
rxasun
Owner Date
WORKERS'COMPENSATION DECLARATION
1 hereby affirm that I have acertificale.fconsenl losel6ins ire,
or a certificate of Workers' Compensation Insurance, or a certified
copy thereof (Sec. 3800, Lab,C.).
Policy No.
MISC. — REFER TO ORD
PERMIT ISS UANC E 6.00
VALUATION
a 3 (—�ro
V
SIFT.
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL / S
' TkU'
� ITV,
Y - "
ALTER -DRAIN & VENT -WATER (EA.) 4.00
PERyMI,T TO
S/N�C6, q/T/iC (/�C
STORIES
Z�
TV CONSTR.
f•-./ ./_
/V 1sCvIERt
BACK FLOW PROTECT. DEVICE 2,DO
OCC. GROUP
_ 3
RES. UNITS
/
DRAINS•FLOOR, ROOF, AREA, COND. 4,00
FIXTURES -PER TRAP q,pp •�
GAS-EA.SYSTEM-1 INC.4OUTLETS 4,00
GAS - EA. SYSTEM - OVER 4 (EA.) 1,00
!6 FT. FLOOR AREA
3i^ O
s
TOTAL ACREAGE
BUILDING USE
RES IND CON PS Om.,
gi 11 11 ❑ 11licensed
INDUSTRIAL WASTE INTER. . 20.
LAWN SPRINKLERS • 1 INC 6 V.B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
3j-6 _ '7_�—
SEWER•SANITARYSTORM EA. 200ft/6.00
WATER HEATER IN/VENT .T q,00
TRACT NO.
P NO.
CEL
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EO ', -;4.00
ZONING
ENG. SITE NO.
a�n/ P nD ' nn
—Company
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division,
Applicant
MISC.- REFER TO ORD.
FIRE SPRINK
v� N�
ENERGY T-24
v� N�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
IThis dollars need not be compbted if the permit a for one
hundred dollars IS eed no less.)
PERMIT ISSUANCE 6.00
FLOOD ZONE A.L.U.C.
Y [] NC3 Y C] NE]
PLG. CONTR. LIC. NO, PLG
TOTAL �Q
I certify that in the pefformance of the work for which this per.
mit k issued, I shall not employ any person in any manner an as to
become subject to the Workers' Compensation Laws of California.
Dale APPLICANT: I
NOTICE TO APPLICANT: If, after making the Certificate of Ex-
ALTER OR ADD TO MEC !� 1 s
f 4.00
BUILDING -7 .ia
/ 70
provision you should berme subject to the Wrthwii Ccomplylion
provisionsuns io the labor Code, you most forthwith Comply with
such provisions or This permit shall be deemed -voted.
APPLIANCE 4.00
AIR HANDLING UNIT (T(.' F.M.) -, 3.00
PLAN CHECK
FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which the permil is issued ISee.
3097, .de,*s Ci,,C.).
).
Lender's Name
AIRHANDLML)N1T( 10MC.F.M.) 5.00
SEISMIC FEE
EXHAUST HOOD TWIT r ert+t6�
MICROFILM
HEATING UNIT (TO 1 B-T,U.) 4.00
Lender's Address
HEATING NIT (OVER 100,000 B.T,U.)7.50
ELECTRIC
1 Certify that 1 have read this application and state that the above
information n cotater. 1 agree to Comply with all city and county
ordinances and state laws relating to building construction, and
hereby authorize representatives of thin city to enter upon the
above-mentioned properly for inspection purpose.
(We) agree to save, indemnify and keep harmless the City of
.upertino against liabilities, judgments, costs and expenses which
nay in ar{Y way aceto �8asnat said City in consequence of the
- o/the p�jrgit MECH.
/W/ /wE//f,/(.
VENTILATION FAN (SINGLE) 3,00
BOILER•CONP I3 H.P. or 100,0008.T.U.) 4.00
PLUMBING //di —7'
B01 LER-COMP IDvwr 100,000 BTU) SEE FEE SCH.
f d,y
MECHANICAL /j
MISC. - REFER TO ORD.
PERMIT ISSUANCE 3 OO •�
CONST. TAX o't'
CONT. LIC. NO.
MECH.
TOTAL 99
/V
f
agnalure of Appoetal/Contractor Date
Ca]��La1�Ha737