5803 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -,USE BALL POINT PEN ONLY
BU LDI NG PROJECT'I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
' S8O3
ADORESs'
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
�•'-'� "AME - OTY: --, ELECTRIC PERMIT FEE
PHONE
NAMERAcroR's OUTLETS-SWITCHES-RECEP 5.00/1.00
UC.No. 40�-1�i'3 . .LIGHTING FIXTURES 5.00/1.00
ADDRESS
CTOR'S 1 , PPLIANCES-RESIDENTIAL 4.00 -
III, :. - PHONE PANELS 5.00 DATE OF'APPLICATION
ARCMIECTSIGNS 6.DD - PLAN CHECK FEE. PO NO,
on
ENGINEER
_ LIC.NO.-
SIGNS TRANS. 3.00
AARCH.OR DDRESS ENG. ' SPECIALCIRCUIT _ •5.00 - PERMIT VALIDATION
ZIP EMP:METER OR POLE INS. - 15.00
PPPL1GA"T's IMOTORS SEE FEE SCH, S
ADDRESS - -
• SERVICE CHANGE 10.00
Wo 0 0. p
F o LICIiNSED CONTRACTORS DECLARATION
1 U u hereby affirm that I am licensed under provisions of Chapter 9 troll ISSUANCE DATE
N w (commencing with Section 7000)of Division 3 of the Business anA
a H SLOG. ELECT. PLG. MECH.
r w z Profcsslons Cnde rid ¢cosi is in full force a i cff t. ❑ ,❑ ❑ ❑
z o m- License C Lia Nwnbcr -
9 4__Conlmctor
a r E J - - BUILDING PERMIT
M0 i U -OWNER-B DILDIiR DECLARATION, INFORMATION
is I- - I hereby affirm that I am exempt from the Contractor's License MISC.- ,+ REFER TO ORD
3 a _ VALUATION -$/FT.
LLNj Lawforthefollowingreason.ch(Sec.
requires
permit tocnd Professions PERMIT ISSUANCE 6.00 _
Code Any city or county which re9uiresa permitnconstruct.alteq 'J (�•-O
a improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. / J -
A Oo a requires the applicant for Such permit to file a signed statement that - TOTAL
o. w m m he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
> Law(Chapter 9(commencingwith Section 7000)o'Division3of
a Business and Professions Code)or that be is exempt therefrom and OTY. PLUMBING PERMIT F EQ.ODr`
Ic the basis for.the alleged exemption.Any violation of Section 7031.5 x STORIES TYPE CONSTR.
a ; by any applicantforapermit subjects the applicant loa civil penalty ALTER-DRAIN$ VENT-WATER IEA) q,0. UTT
of not more than five hundred dollars($500).).
�.�KE
. ❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE
their,sole compensation,will do the work,and the structure is not 2.DD OCC.GROUP RES.UNITS
intended or offeredforsale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.0 of C O
Code:The Contractor's License Law does not apply to an owner of Vit* �g' L
• • property_ m
who builds or improves thereon,and who does such work ' FIXTURES-PER TRAP _ 4.00 sO.Fr.FLOOR AREa TOTALACREAGE
himself'or through hie awn employees,provided that such improve-
mentsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
or improvement is,sold within one year of completion.the owner. GAS-EA.SYSTEM•OVER 4 IEA.) 7.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
,. prove for purpose of sale.)., INDUSTRIAL WASTE INTER. - 20.00 RES IND CON PB Other
❑ I,as owner at tire.properly,am exclusively cmdraeling with ❑ ❑ ❑ ❑: , El
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 dries 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 corracb+ds)licensed pursuant to - SEWER-SANITARY-STORM EA.200Tt/6.00
the Contractor's License law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT, •4.00 '
reason
Owner Date WATER SYSTEM' 4.00 •. ACC.DATE ACC.FILE NO.-,
WORKI!RS'COMPFNSA'I'ION DECLARATION WATER TREATING EQUIP. 4.00
. I hereby affirm that I have a certificate of consent tet set Gimure' ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
. . copy thereof(Sec.3800,Iab.C.L
PolicY.No. Company -
O ❑ .Certified copy is hereby furnished. • FIRESPRINK ENERGY T-24
Z Zp' Certified copy is tiled with the city inspection division. MISO.'- - ' REFER TO ORD.
O Applicant - Y❑ No .Y❑ ' N❑
M N CERTIFICATIi OI'HXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
Lu COMPENSATION INSURANCE PLG.CONTR. r LIC.NO. PLG. -
CL Z' (This section need not be completed if the permit is for one TOTAL' '• Y❑ - N C] Y [:] N E]
hundred dollars IS 100)or less.)
U OI tify that in the performance of the work for which this per DTV. - MECHANICAL PERMIT FEE FEE SUMMARY
11 H •mil ceris'issued,I slmll not ciisploy tiny person in any mm�ner so as Io
o becOm-sthe Workers'Com t�ensScion Laws of alit I
Dare_Yr^�Applicunt�-p1----1 BUILDING .CrLSL .�z1
a ALTER OR ADD TO MECH. 4.00
ED NOTICE TO APPLICANT i'If,after makinµthis Cerl ificate of fix -
).... Z �emplion,you should become suhject to the Workers'Connpensution APPLIANCE , 4.00 'PLAN CHECK
provisions of the labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be devoted revoked. AIR HANDLING UNIT(TO 10=C-F.M.) 3.00
.s •CONSTRUCTION L17NDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 5.00 . SEISMIC FEE .D
I hereby affirm that there is a construction lending agency for EXHAUST HOOD,(WITH DUCT) 2.00 -
tire performance of tum work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
'Lender's Name HEATING UNIT(OVER 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
irroc ation 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.or 100,000 B.T.U.)"4.00
hereby'authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU(SEE FEE SCH. MECHANICAL
abome
ovntianed property for inspection purposes.
(We):agree tet save, indemnify and keep harnless the City of MISC.-' - REFER TO ORD..
Cupertino against liabilities,judgments, costa and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in consequence of the
granting of[his ermit. MECH.CONT. - LIC.NO. MECH.' -
C�l Tornv TOTAL
Signature of Applicant/Con[rac r Date '
OFFICE COPY I - ,
OFORMIE ROM
^ 3821 Marfrance Drive, San Jose, CA 95121`
Phone (408) 281.3193
• Contractor: DON B. HALL License No. 405193
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