3589 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -'USE BALL POINT PEWONLY
BUILDING PROJECT I DENTI FICATION ? +" • • ' PERMIT NUMBER
aD,LD,NG. - ,APPL'ICATION.& PERMIT -
• , — — + � 4UILDING,—ELECTRICA L-PLUMBING—MECHANIC -' -
3,589
NEE' - -- - � � � - .�- - �—_—'-'�� �� PLAN CHECK VALIDATION
ELECTRIC PERMIT FEE
rHLN _ 11
CONTRA Ton's - OUTLETS-SWITCHES;RECEP 5.00/1.001
PLUMPWG LIGHTING FIXTURES 5.00/1.00
NT blzabI burrLy APPLIANCES-RESIDENTIAL 4.00
ADO R ss
f PANELS S.00 DATE-OF APPLICATION'.
ARCHITECT - SIGNS 5.00' PLAN CHECK FEE,;, P.C.NO. ,
1,
7 fivst Street :a San Jose,CA 95110
SIGNS TRANS 3.00 '
ARCH.OR ENG. `PERMIT VALIDATION
ADDRESS ' -T' SPECIAL CIRCUIT,',.'. 5.00 .
• - 2,P EMP.METER OR POLE INS. 15.00'.
APPLICANTS, MOTORS SEE FEE SCH.
ADDRESS'
' SERVICE CHANGE 10.00
0 C 0 LICENSED CONTRACTORS DECLARATION
_a i I hereby affirm that'I am licensed under provisions of Chapter 9 - ISSUANCE GATE _
_N et y (commencing with Section 7000)of Division,3 of the Business and BLDG. ELECT. L MECH.
Profession s��ood license is in ful af�pf�
z O y'� License Cldr<•r Lic.Numb ,Q t" a �t
wr a Data Coal racto,
y���,�t���—�,
a m J p R N� BUILDIN PE MIT
¢ ¢ ¢ OWNER-BUILDER'DECLA TT10
¢ w u- 'INFOR ATION
w ; E. I hereby affirm that I,am exempt from the Contractor's License MISC.- - REFER TO ORD y
H ¢ O J. Law for the following reason.(Sec.7031.5,Business and Professions ,PERMIT ISSUANCE 6.00 VALUATION $/FT.
,A w Code:Any city or county which requires a permit to construct,alter,
rc 4 o improve,demolish,or repairany structure,prior to its issuance,also ELEC.CONTE. - LIC.NO. ELEC.
a- u requires the applicant for such permit to file a signed statement that .- _ TOTAL PERMIT TO
`<m he is licensed pursuant to the provisions of the Contractor's License _
wZ>-•. Law(Chapter 9(commencing with Section 7000)of Division 3 of the
H
a- Business and heallgd Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
F t o
.¢ H �, the basis for the alleged ezemp[ion.�Any'viola[ion ot'Seclion]031.5 - STORIES T ECONSTR.
a3 _ by any applicant fora permit subjects the applicant to a civil penalty gLTER-DRAIN&VENT-WATER (EA.) 4.00 I
of not more than five hundred dollars(S500L) - ,K
❑ 1,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 r
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 50.FT,FLOOR AREA TOTAL ACREAGE
• himselfre through his own employees,provided that such improve- GAS-EA.-SYSTEM-1 INC.4OUTLETS 4.00
menta are not ugh his or offered far sale.If,however,the improve.
'or improvement is sold within one year of completion,the owner- GAS-EA'.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or int, IND CON 'PR Omer, '
.prove for purpose of sale.). INDUSTRIAL WASTE INTER. .2000 ❑ '❑ .' ❑ El
I,as owner of the property,am exclusively contracting with .
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO. 1
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
contmets.for such projects with a contractor(s)licensed pursuant to SEWER-SANITARYV-STORM`EA.200f[/5.00
the Contractor's License Law. 1 TRACT NO. PARCELNO.
❑ l am exempt under Sec ,B.&P.C.for this
WATER HEATER W/VENT 4.00
reason
Date - Owrier'' WATER SYSTEM 4.00 ACC.OATE ACC.FILE NO.
WORKF-RS'COMPENSATION DECLARATION t WATER TREATING EQUIP. 4.00
I hereby affirm that 1 have a certificate of eonsenl to self-nsinc. ZONING
"or a certificate of Workers'Compensation Insurance,or a certifi ENG.SITE NO.
_
co t re S. 0 ). - _ r'
A2 1 11
0 ED PCetliBeOy l'urnie ted. - FIRE 6PRINK ENERGY T 2
- Z_ ZO ntlifieJ c is ded with th c m cction division. MISC.- REFER TO ORD. Y ❑ 'N❑ Y ❑' N❑
PP
♦— rn' - PERMIT ISSUANCE .`6.00
LU — . .CERTIFICATEPE EXEMPTION FROM KERS' FLOOD ZONE - A.L.0 c.
W.1 COMPENSATION INSURANCE PLO.CONTR: LIC.No. PLG. '
CL a( This section need not be completed If the permit is for one _ TOTA y❑ N 13; N❑ y ❑ -.
hundred dollars(S 100)or Tess) -
U O 1 certify that in the performance of the work for which this per- OTV, MECHANICAL PERMIT FEE FEE SUMMARY
LL.F. „ •mit is issued,1 shall not employ any person inany manner so as to
U become subject to the Workers'Compensation Laws of California. .
O m Date Applicant BUILDING +
a - ALTER OR ADD TO MECH. 4.00
} W NOTICE TO APPLICANT. If,after making this rs'Come sa Lx- 't
FZ emvisionyou shouldbecomesubject to the Workers'Compensation APPLIANCE s ,4:00 PLAN CHECK ^
Such ions iof ons or Labor Code, you must forthwith comply with .I FEE '-
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000 C.F.M.) 3.00 ^
--' CONSTRUCTION LENDING AGFNCY' AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE'.
I'hereby affirm that there is a construction lending agency foi EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit Is Issued'(Sea. MICROFILM'
3097,Civ.C.L • - HEATING UNIT(TO 100,000 B.T.U.)'. 4.00
Lender's Name HEATING'UN IT(OVER 100,000 B.T.U.)7.50
Lender's Address ''� = ELECTRIC -
Icertifythat l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 '
• information is correct.I agree to comply with all city and countyPLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.or100,000B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. _ MECHANICAL
above-mentioned property for 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 PERMIT ISSUANCE - 3.00 CONST.TAX '
m in any wagroo against said City in consequence of the
a
,an
of is.pMECH.CONT.;i LIC.NO. TOTAL TOTAL pC trac or ate - /
OFFICE COPY -
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