3077 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONL
BUILDING PROJECT IDENTIFICATION vE UMBER
BUILDING APPLICATION & PERMIT 3077 7 r]
DDREss I
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
PL ,N
ELECTRIC PERMIT - F.EE� PUBLIC WORKS
e ...i ?f.
CDNTRAC 'SFEB 241983
OUTLETS-SWITCHES-RECEP 5.00/1.00
NAME
. r� T�� ACE LIC.No � 7 LIGHTING FIXTURES 5.00/1.00
ioNXV PPLIANCES-RESIDENTIAL 4.00 RECEIVED,
PANELS 5.00 DATE OF APPLICATION
AIA� So FIRST S=EET
G SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ErN+GISAN JOSE, CA 95110
.NO. SIGNS TRANS. 3.00
ADDRESSs E SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00 /J
AvvLlcarvrs MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
woo LICENSED CONTRACTORS DECLARATION p(�
a u u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
N<. (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT.I PLG. MECH.
w oi Profession 9d license is in full of
c i =W License CIC : ,I Lic.Numbe eiam ❑ ❑ ❑
Date Centric
tor-� -
a �-'ONF J "B INFOR PERMIT.;'ifZ;^
¢ o i u OWNER-BUILDER DECLARATION Qi:= ,h71NF.ORMATION jyi' .+',�v
E
g w m I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD -'
FILO) Law far the following reason. 7031.5,Business and Professions PERMIT ISSUANCE VALUATION $/FT.
6.00
F W f
Code;Any city orcounty which requires a permit to construct,alter, ELEQ CONTR. LIC.NO.
re ¢ < O improve,demolish,or repair any structure,priar to its issuance,also ELEC.
wO u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
$ he is licensed pursuant to the provisions of the Contractor's License _
Fzi
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
E o Business and Professions Code)or that he is exempt therefrom and OTY. -'PLUMBING PERMIT - F- - 'FEE_'.
¢ F $ the basis for the alleged exemption.Any violation of Section 7031.5 fSTORIES TYPE CONSTR.
i ; •. byanyapplicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not mare than five hundred dollars(SS000:
❑ 1,as owner of the property,ar 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,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
y ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM•1 INC.4 OUTLETS 4.00
• or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Dire,
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ d as owner of the property,he exclusively contracting mess ❑ ❑ ❑ ❑ ❑
licensed caion, odtoconstruct the project(Sec.La. 7044.Business LAWN SPRINKLERS-1 INC5 V.B. 5.00 ASSE$SORSPARCELNO.
and Professions Code:The Contractor's License Law does not applywho
toan trowner of property who builds trimproves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1,00
contracts for such License
ts Lwith acontmctorlsl licensed pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ 1 am exempt under Sec. B.&P.C.for this WATER HEATER W/VENT 4.00.
eason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate ofconsent to self-insure. ZONING
a,acertificate of Workers'Compensation Insurance,or ed ENG.SITE NO.
�Do.
t} �yILH11.�`O / e ified copy is hererbyf.Nm hed. FIRE SPRINK ENERGY T24
Z 2 Certified is Ile with th ' e' n division. MISC- REFER TO ORD.Q mart Y❑ No Y ❑ N❑
~ va PERMIT ISSUANCE 6.00
� - I CERTIFICATE OF EXEMPTION FROM W ERS' FLOOD zorvE A.LA.C.
Lu �_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This section need not be completed if the permit is for one TOTA Y❑ - N❑ Y❑ N❑
� Z hundred dollars IS 100)or less.) +" 11' ',:-?, ..,'s.+ v jq, pit, V;�•�s.-� o '� rn..• s --- -
U O I certify that in the performance of the work for which this per. DTV. ~MECHANICAL PERMIT = if FEE ;-; FEESUMMARVs.-� .5
LL F- mit is issued,I shall not employ any person in any manner so as to I w:`•i bt fig'
U become subject to the Workers Compensation Laws of California. "f-
0 a Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} m NOTICE TO APPLICANT: IL after making this Certificate of Ex-
2 emption,you should became subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply will] FEE '
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.NL) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.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 H EATING UNIT(OVER 100,000 B.T.U.)7.50
Lenders Address ELECTRIC
I certify that I have read this application and state thin the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county BOILER-COMP13 H.P.or 100,000 B.T.U.) 4,00 PLUMBING
ordinances and state laws relating to building construction, and
. hereby enthoriec representatives ec this city es enter upon the BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
hereby entioned property far inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against Said City in consequence of the PERMIT ISSUANCE 3.00
ting of hisp iI MECH.CONT. LIC.NO. MECH. (,
TOTAL
/}2> :;,TOTAL".."
naureol'Applicant/Contractor ale '^';4f;*ird..!� �
OFFICE COPY