2530 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI. POINT.PEN ONL
YM
BU I LDING PROJECT I DENTIFICATI ON PE UMBER
aDILDING - APPLICATION & PERMIT [ 0
OOR ES `1
BUILD
ING -- ELECTRICAL=PLUMBING -MECHANICAL
OWNER'S _ PLAN CHECK VALIDATION
Name GTY. ELECTRIC PERMIT FEE
p
'C FACTOR'S -
NAmEACE ! _ OUTLETS-SWITCHES-RECEP 5.00/1,00
G uc.N LIGHTINGFIXTURES 5.00/1.00
noo APPLIANCES-RESIDENTIAL 4.00
SO. FIRST STRKET PANELS 5.00 - -DATE OF APPLICATION
a cw1E' SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGy�4' JOSE, CA 95110. '
.ND. SIGNS TRANS. 3.00
ADDRESS ARCH E - SPECIAL CIRCUIT 5.00 •PERMIT VALIDATION
211 TEMP.METER OR POLE INS. 15.00 '
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
'02 LICENSED CONTRACTORS DECLARATION
a v u 1 hereby affirm that I am licensed under provisions of Chapter 9 .'
n 2 w ISSUANCE DATE
< s. (commencing with Section 7000)of Division 3 of the Business and
r w 2 Pro fessioas CO a license is i0 full d a o BLDG. ELECT. PLG. MECH.
o O m D License Class- Ir _Lic.Numbe '� lyl
Dale Codirect.,
M¢ Y`1a
4 y
¢w OWNER-BUILDER DECLARATION BUILDING PERMIT
w ; LL yI hereby affirm that I am exempt from the Contractor's License M ISC.- REFER TO ORD INFORMATION
ic LLD ¢, Law for the following reason.(Sec.7031.5.Business and Professions - VALUATION
E $/FT.
Code:Any city or county which requires a permit to construct,alter, PERMIT ISSUANCE 6.00
w Y ELEC.CONTR. LIC.N0.
¢ ¢ O demolish,Or repair any structure,prior to its issuance,also ELEC. _
i 4 improve,'D¢ requires the applicant for such permit to file a signed statement that TOTAL
PERMIT TO
w$ he is licensed pursuant to the provisions of the Contractor's License
F z a Law(Chapter 9(commencing with Section MOO)of Division of lite 1,
i o Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN (EA.),4.00
of not more than five hundred dollars($5001.):
❑ I,as owner the property;or my employees with wages as .
their sole compensation,will the work,and y e structure is not BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RESUNITS
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 SD.FT.FLOOR AREA TOTAL ACREaeE
himself or through his own employees,provided that such improve-
dents are not intended or offered for sale.If,however,the building GAS-EA.SVSTEM-l1NC.40UTLETS 4.00 .
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or an. GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER.. 20.00 RES IND . CON PB' Other
❑ I,as owner of the property,am exclusively contracting with 0
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-d INC 5 V.B. 500 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 such projects with a conldcloris)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM%EA.200ft/B.00 TRACT NO. PARCEL NO.
❑ lam exempt under See.-,BAPC.for this WATER HEATER W/VENT 4,0
reason99
Date Owner WATER SYSTEM - 4.00 ACC.DATE ACC.FILE NO. .
WORKS RS'COMPENSATION DECLARATION WATER TREATING EQUI 4.00
1 hereby affirm that I have a certificate of consent to self-insure, - -
or a certificate of Workers'Compensations�Ins�urance,or¢a+certified ZONING ENG.SITE NO.
rAA'!
IhP erg 0 ab.C.). \ak X� It d►1b \ _DEC
O Certified copy Is hereby furnished. FIRE BPRINK ENERGY T 24
Z Z, [CItt d y-is filedI 1 ie ity Inspection division. BDY❑ NY ❑ �N�� O plicant�l N1 � MISC.- CIty�F R
cc 75 CERTIFICATEOP EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.04 FLOOD ZONE 'A.L.UC.
W 0 Q. COMPENSATION INSURANCE PLG.CONTR. -' . ' UC.NO. PLG. �+r i
O (This section need not be completed if the permit is for one; IOTA - Y N❑- V ❑ N'' x
Z hundred dollars(S 100)or less) ,{
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 in any manner so as to
O become subject to the Workers'Compensation Laws of California.
y Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING •jP^
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
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 -
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10pWC.F.M.) 5.00 SEISMIC FEE
1 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(TO100,000 B.T.U.) 4,00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 IELECTRIC
I certify that I have read this application and state that the above VENTILATION-FAN (SINGLE) 3,00
Ordina Ordinances
n correct I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, andmy BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP IOvar 100,000 BTU)SEE FEESCH.
above-mentioned property for inspection purposes. MECHANICAL
1' (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
gting Of IN rntiL - MECH.CONT., - - LIC.NO.1 MECH,
TOTAL TOTAL
lure of Applicantcontractor
_ ` OFFICE COPY _ -