3340 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI: POINT PEN ONLY
BUILDING PROJECT IDENTIFICATIONP RMI BER
BUILDING , ' APPLICATION & PERMIT
A°DREs t
/� O -
' Ar BUILDING -ELECTRICAL-PLUMBING-MECHANICAL ,
WNER's PLAN CHECK VALIDATION '
"A OTY. ELECTRIC PERMIT FEE
CONTRP
NAMe"OTOUTLETS-SWITCHES-RECEP 5.00/1.00 "
rAoD . 00 N LIGHTING FIXTURES 5.00/1.
RLmbow b(iyynVICE -APPLIANCES-RESIDENTIAL 4.00
'
PHONE PANELS 5.00 DATE OF APPLICATION
AR • SIGNS 6.00 PLAN CHECK FEE P.C.N0. ,
OR
ENGmSAN 'JOSE, CA %51d O. SIGNS TRANS. 3.004475 '
ARCH.OR ENG 6408) .297107 SPECIALCIRCUIT 5.00 PERM IT VALI DATION
ADDRESS VYV -
'ZIP TEMP.METER OR POLE INS. 15.00
A - MOTORS SEE FEE SCH.
ADDRESSDDRESS
SERVICE CHANGE. 10.00
woo 'LICENSED CONTRACTORS DECLARATION
< 2 u 1 hereby affirm that I am licensed under provisions of Chapter 9 r 'ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT: PLG. MECH. -
iProfessions Coif%a license is in full fu ee((feeL��t�"1' �-y ❑ ❑ ❑ '
Z,O= License Class( = Lic.Numberyl_CZV.,. -'
O r Date Contractor�L-n -
¢ r s � �''`�-i- BUILDING PERMIT
¢ ¢ w
OWNER-BUILDER'DECLARATION INFORMATION
w;OA MISC.- REFER TO ORD -
g a-y I hereby affirm that I am exempt from the Contractor's License VALUATION. $/FT.
Huoar Law for the following reason.(Sec.7031.5,Bmaressand Professions PERMIT ISSUANCE 6.00
Code:Any city or.county which requires a permit to construct,alter, - -
Q ¢ Q p improve,demolish,or repair any structure,prior t0 its issuance,also ELEC.CONTE. LIC.NO. ELEC. -
- o ¢ requires'the.applicant for such permit to file a signed statement that TOTAL' PER MIT TO
N w w he Is licensed pursuant to the provisions of the Contractor's License
HiQLaw(Chapter 9(commencing with Section 7000)of Division 3 of the - -
i o Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ H $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
aby any applicant for a permit subjects the applicant to a civil penalty' ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars($500).)'. '
❑ I,as owner of the property,or 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 a of rote his own employees,provided that such improve-
ments mself me not dad oroffered oyees,provided
that such
emprovg GAS-EA.SV STEM-11NC.40UTLETS 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 int- RES IND CON PB� Ona,
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with ❑ F-1 : ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-I INC 5 V:B. , 5.00 ASSESSORS PARCEL NO. '
and Professions Code:The Contractor's License Law does not apply -
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 -contracts for forsuch projects with a contractons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY.-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I l am exempt render Sec. - ,BAP,C.for thisWATER HEATER W/VENT '4.00 - -
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACL FILE NO.
WORKF-RS'COMPP,NSATION DECLARATION WATER TREATING EQUIP; 4.00
I hereby affirm that 1 have a certificate of consent t0 self-insure, - ZONING ENG.SITE NO:
or a certificate of Workers'Compensation Insurance,or a certi led
coB(ih��ryy�o ,l by
J. - .'•
PoMy,➢1O� -
O ❑,Celtlfie copy is hereby lurnishc , FIRE SPRINK ENERGY T-24
Z 2 1�.CJrlified is fled witll t) e [on division.
NO PAP MISC.- REFER TO ORD. Y❑ N,❑ 'Y ❑ N❑
an' PERMIT ISSUANCE 6.006- FLOOD ZONE" A.L.UC.
CC ; CERTIFICATE OF EXEMPTION FROM WO RS' _
W COMPENSATIONfarbeoto INSURANCE. PLG.CONTR. LIC.NO. PLG.'
� Z (This section need not be completed if the panni[ is for one 'TOTAL (rr Y❑ - N❑ Y ❑' N❑
hundred dollars($100)or less.)
U O -1 certify that in the performance of the work for which this per- DTV MECHANICAL PERMIT FEE FEE SUMMARY
LL I- 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.
w Date Applicant I BUILDING
a ALTER OR ADD'TO'.MECH. 4.00
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex- -
F Z 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
V such provisions or this pennit shall be deemed revoked. AIR HANDLING UNIT(TO 10MOC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0=C.EM.) 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. MICROFILM
3097,Civ.C.) HEATING UNIT(TO 100,000 B:T.U.) 4.00 _
Lender's Name
Lender's Address H EATI N G UN IT(OV ER 100,000 B.T.U.17.50 ELECTRIC
1 certify that I have read this application and stale that the above VENTILATION FAN (SINGLE), 3.00 .�
information is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.).4.00 PLUMBING
ordinances and state laws relating to building construction,',and
hereby authorize representatives of this city to enter upon the BOILER-COMP IOvar OO,0DOBTUI SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
i :(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
nyfAin any way accrue against said City in consequence of the PERMIT ISSUANCE ,3.00
an ng ofllls e!rtt}. MECH.CONT. ;LIC.NO. MECH. -
TOTAL TOTAL
ah eo App can C reactor, c -
OFFICE COPY