2890 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONL
ERMI BEP
BUILDING PROJECT I DENTIFICATION APPLICATION &-PERMIT �Q90
BDILDINc - V
oREss
TBUILDING -ELECTRICAL-PLUMBING-MECHANICAL
PLAN CHECK VALIDATION
O s
DTV. ELECTRIC PERMIT FEE
vHo
CONTRACTOR UTLETS-SWITCHES-RECEP' 5.00/1,00
NAME
LIGHTING FIXTURES 5.00/1.00
ACE.� Lm..IIN .. -
AO'�VTBING SERVICE . PPLIANCES-RESIDENTIAL 4.00
PANELS 5.00 DATE OF APPLICATION
%T ST-ftirer SIGNS 6.00 PLAN CHECK FEE P.G NO
0,
.
0,NR _SAN JOSE, CA 95LJc1Ik9 SIGNSTRANS. 3.00
AR '°R ) SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ADCHDRESS
ZIP EMP.METER OR POLE INS. • 15.00
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS
' SERVICE CHANGE 10.00
woo LICENSED CONTRACTORS DECLARATION
te w - ISSUANCE GATE
a u u I hereby affirm that I um licensed under provisions of Chapter
H G w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H D i Professions C icense is in full fysf (f�jfx !Z ❑ ❑
i O w License Cl4ss Lic.Numhe ,y(,.1J_L
9 H w El El
Dale Contractor
BUILDING PERMIT
st st wu OWNER-BUILDF-R DECLARATION INFORMATION
X ; u w 1 hereby affirm That I um exempt from the COnhactor s License MISC.- REFER TO ORD ygLUATION S/FT.
H u O j Law for the following reason.(Sea 7031.5,Businessand Professions PERMIT ISSUANCE, 6.00
M Code:Any city Orcounty which requires a permit to construct,alter,
4 p improve,demolish,or repair any Structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC.
requires the applicant for such permit t0 file a signed statement that TOTAL - PERMIT TO
w $m he is licensed pursuant to the provisions of the Contractor's License -
ac z r Law(Chapter 9(crmmencingwllh Section 7000)of Division 3 OCthe
� i c Business and Professions Code)or that Ire is exempt therefrom and OTY. PLUMBING PERMIT FEE
Ic the basis fonthe alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ; by any applicant for a permit subjects the applicant toil civilpenalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(SSOOM:
❑ 1,as owner of the properly,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 F IXTUR ES-PER TRAP 4.00 50.FT,FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided that such improve
hioodsmself are not his or ffered foremploycesnW.ILed that clhebmldingo'e- GAS
or
SYSTEM-I INC.4 OUTLETS 4.00
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- RES IND CON PB Other
prove for purpose of sale.). . INDUSTRIAL WASTE INTER. 20,00
❑ I,as owner of the property,am exclusively contracting with ❑ EI ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 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 IEA.1 0.00
contracts fro mch projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO.
the Contractor'.%License Law. PARCEL N0.
❑ -l am exempt under See,..B.&P.C.]or this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 Acc.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm flint I have ucertifictnu of cnnsem to sclbinsure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensattio(n`�his d
. Ipgv Ili,�rf�f, .318pp-lyutyy.).
0 IN, opy is hereby I ufnished. HRE SPRINK ENERGY T 24
Z Z ?9�Certifip�i�Bled with the city inspection division. MISC.- ' REFER TO ORD. Y❑ N❑ Y ❑ N❑
H pphCunt-oma,
� y
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE r 6.0 FLOOD ZONE A.L.UL.
Lu >_ COMPIENSATION INSURANC17 " PLG.CONTR. LIC.rv0. PLG. v❑ N❑ v ❑ N❑
CL 0 (This section need not be completed if the permit is for one TDTA
Z hundred dollars($100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
)- mil is issued,1 shall not employ any person in any manner so us to
O W become subject to the Workers'Compensation Laws of California. BUILDING
Date Applicant ALTER OR ADD TO MECH. 4.00
}
to NOTICE TO APPLICANT: If,after making this Certificate of fix-
2 eoption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000 C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.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.CJ.
Lenders Name HEATI NG UN IT(OVER 100,000 B.T.U.P.50 ELECTRIC
Lender's Address
1 certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
NJ information is correct. I agree to comply with all city and.county. gO1LER-COMP(3 H.P.Dr 100,000 B.T.U.) 4.00 PLUMBING NG s
•\ ordinances and state laws relating to building construction, and
1 hereby authorize representatives °f this city to enter upon the __7F
hereby (Ova,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
may in any way accrue against said City in consequence of the
gr itin of tl' clout. MECH,CONT. LIC NO'. MECH. /
OT"` TOTAL il��
S' a roof Applicant/Contractor Date' v
OFFICE COPY