3587 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN.ONLY
BU I LDING PROJECT I DENTIFICATI ON PERMI NUMBER
BUILDING
APPLICATION & PERMIT C p
RE55 (LDiJ 0
ING-ELECTRICAL-PLUMBING-MECHANICAL
71
10 j;, 'S - _ _ - PLA CHECK VALIDATION
" r6eTV. ELECTRIC PERMIT FEE
P
io
CONTRA TORS UTL ETS-SWITCHES-RECEP 5.0011.00
PLUMBING LIGHTING FIXTURES 5.00/1.00
Paz
PP LI ANC ES-RESIDENTIAL .4.00
PANELS 5.00 PATE OF APvucgnoN
CSIGNS 6.00 PLAN CECP.C.NO.
. First Street • San Jose, CA 9511
1910phone (408) 29M407-- SIGNS TRANS. 3.00
ADDRESSS SPECIALCIRCUIT 5.0Q PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANT'E /
ADDRESS MOTORS SEE FEE SCH. /Js,
SERVICE CHANGE 10.00 71
/D1r/�
woo LICENSIiD CONTRACTORS DECLARATION d"
a w I hereby affirm that I am licensed under provisions of Ch:qucr,9 ISSUANCE DATE
y (commencing with Section 70001 of Division 3 of the Business and
a n BLDG. ELECT. PLG. MECH.
i Prose Class nrkqyyc ensu is in full for c ❑ ❑
0 i= I] License Class Lin.Number
Date Contractor
a y f BUILDING PERMIT
Ic ¢ a OWNER-BUILDER DECLARATION
A o a u INFORMATION
x ; N 1 hereby affirm that I am exempt from the Contractor's License MISC.,- REFER TO ORD
LL o 4 Law for the following reason.(Sec.7031.5,Businessand Professions VALUATION S/FT.
L _ s PERMIT ISSUANCE 6.00
rtm� Code:Any e.demyor shcor ntywhich structurepermit toconsuaricalter, -
M a p improve,Demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.,NO. ELEC.
s. C u requires the applicant for such permit to file a signed statement that - TOTAL PERMIT TO
w a he is licensed pursuant to the provisions of the Contractor's License pp
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
i c Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
I-m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
s; -- by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(b500)J:
❑ I,as owner cut the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2,00 OCC.GROUP REB.UNITS
sole compensation,will do the work,and the structure is not
intended or offered for sale (See. 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 throu
ghde ownemployees,for
ssle I f.ed that however,
the
Improve GAS-EA.SYSTEM-1 4.00
mems an not intended or offered for sale.If,however[he building
or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4(EA.) 1.00
builder will have the harden of proving that he did not build or im BUILDING USERES IND CON PS Omer
prove 1.as ofor wner
cut the.).' INDUSTRIAL WASTE INTER. 20.00 0 El Q - ❑ 11
❑ h as owner of the property,he exclusively contracting with
licensed contractors to construct the project(See.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License s th does not apply
to contracts
owner of property who builds tr improvesehereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
thCon for such cense L with a contractors)licensed pursuont to
the Contractor's License Law. I ISEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO. -
❑ lam exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.0
reason
Date Owner WATER SYSTEM RAI 04.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSAT1ON DECLARATION WATER TREATING EQUIP. 4�.a0q0
1 hereby affirm that I have a certificate of consent toself-insure, vI7x l ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certif•d
cupy40yr of .ah . .
PA 10
ol
Q \❑�rlified top here by furnished OQ FIRE SPRINK ENERGY T2
Z ZO ("" - ified .i Ile with t it anion division. MISC.- ERT ORD. y N Y INC]
Cr �2 CF-RTIFICATF,OFi:XEMPT10Nl'ROA7 KF-RS- .' I PERMIT ISSUANCE 6.00660 FLOODZONE A.LU.C.
d0 COMPENSATION INSURANCL PLG.CONTR. LIC.NO. TED
OTAL'O( V NEEJ Y N
0 Z (This section thit i
need not be completed if- e perms for one
hundred dollars($100)or less.)
U O 1 certify that in the performance of the work for which this per, OTV. MECHANICAL PERMIT FEE FEE SUMMARY
ly T- mit is issued,1 shall not employ any person in any mummer so as tD
0 W become subject to the Workers Compensation Laws of Calitornia.
y Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} w NOTICE TO APPLICANT: If,after making this Certificate of P-x-
H ? emption,you should become subject to the Workers'Compensation APPLIANCE I 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=11F.M.) 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
erforC ance of the work for which this permit is issued(Sec HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
Lender's NamAddress
H EATI NG U N IT(OV ER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I 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 county PLUMBING
ordinances and'state laws relating to building construction, and BOILER-COMP(3 H.P.Dr 100,000 B.T.U.) 4.00
hereby authorize representatives of this city ID enter upon the BOI LER-COMP (Over 100,000 BTU)SEE FEE SCH, MECHANICAL
above mentioned property for inspection purposes.
- (We) agree to Bove, indemnify anti keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
m in any way accrue against Said City in consequence of the PERMIT ISSUANCE 3.00
anti D this od MECH.CONT. LIC.NO.- MECH.
omi TOTAL TOTAL
g ur o Applicant/Comructur ULU IO4
OFFICE COPY