2900 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI. POINT PEN ONLY
BUILDING PROJECT IDENTIFICATIONPE IT BE
a°ILDING APPLICATION & PERMIT (�OO
R S �!
u q �a NG-ELECTRICAL-PLUMBING -MECHANICAL
ER'a _ - PLAN CHECK VALIDATION
N E QTY. ELECTRIC PERMIT FEE
° �. +
CONrne ACTORS UTLETS-SWITCHES-RECEP 5.00/1.00
��r��MACE LIC.NDG O LIGHTING FIXTURES 5.00/1.00
EO-MBING SERVICE PPLIANCES-RESIDENTIAL 4.00cl -
PANELS' - 5.00 DATE OF APPLICATION
OR�..aLJ�, SIGNS 6.00 PLAN CHECK FEE P.C.NO.
FNN JOSE, CA 95110
Uc.No. SIGNS TRANS, 3.00
ARCH oR SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
SS
ZIP TEMP.METER OR POLE,MS. 15.00 /��//J� PAID
APPLICANTSMOTORS SEE FEE SCH. JJ-r� FEBADDRESS
r GD 16 1983
SERVICE CHANGE 10.00 3(
0 0 o LICENSED CONTRACTORS DECLARATION CIt O� �l�I of g111O
Q u o I hereby affirm that I am licensed under provisions of Chapter 9 ISSUA E A P
y a n (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H n i I'mtessions j7y1 a license is
x in lullbe I' /je
z o - Licenu CIaSs;�_ _Lic.Num - r 0 11 ❑
9 r w Date Contractor
Em -J+ BUILDING PERMIT
S,¢ w u OWNT:R.B UILUIift DECLARATION
X 3 u H 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD INFORMATION
u o ¢ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE VALUATION
f �A 0I Code:Any city orcounly which requires a permit to construct,alter,
6.00
2 ¢ ¢ O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
y F 0 LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
au m m he is licensed pursuant to the provisions of the Contractor's License
r z> Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe ,
¢ Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
w =$ the basis for the alleged exemption.Any violation of$ection 7031.5 STORIES TYPE CONSTR.
Ate _ by any applicant for hundred
subjects the applicant toacivil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(2500).):
❑ 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,AR EA,COND. 4.00
Code:The Contractor's License Law does not apply to in owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SD.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- -
I ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00 -
or improvement is sold within one year of conspletion'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 GIN.,
prove for purpose of sale.). - INDUSTRIAL WASTE INTER. 20.00
CI -1,as owner of the property,am exclusively;romracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project tSec.7044,Business LAWN SPRINKLERS-1 tNC 5 V.B. - 5.00 ASSESSORS FARCE L NO.
and Professions Code:The Cmunmel is 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 such projects with a contmetom s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACTNO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.forihis 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 that 1 have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of W.,Ioerlss''yCo�mpercx2 nsu n or a certified -
c o `h� ! F -
Q ❑ ertified copy is ere yf with
... FIRESPRINK ENERGY T-24
Z Z Certified c 's fled with the i n 'rixion'
O MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
A p6 unt
~ w - PERMIT ISSUANCE B.0 v FLOOD ZONE A.L.U.C.
LU COMPCERTIFICATE E EXEMPTION FROM WORK'
W _ F:NSAT'ION INSURANCE PLG.CorurR. LIC.NO. PLG,
1 0 (This section need not be completed if the permit is for one TOTAL I 0,M Y❑ No , Y ❑ N❑
:) Z hundred dollars(S100)or less.)
U O 1 certify that in the performance of the work for which(his per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
ly F 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.
y Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} to NOTICE TO APPLICANT: IL after making this Certificate of Ex-
emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with - FEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT ITO 10/100C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.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. MICROFILM
3097,Civ.CJ. - HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lenders Address HEATING UNIT(OVER 100,000 B.T.U.P.50 ELECTRIC
I certify that 1 have read this application and stem that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP 13 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000BTU)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 CONST.TAX
J�
may in any way accrue against mid City in consequence of the PERMIT ISSUANCE 3.00
tidg f th permit. MECH.CONT. LIG NO. MECH.
TOTAL TOTAL
rApTeMAPpRcant7Cblf1rac or
OFFICE COPY