1591e
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION &PERMIT
BUILDING -ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
1591
aD,L ING
AOp
•NE
NAME
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
-
HONE
CUNT
NAMERAc OR's
OUTLETS -SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES .5.00/1.00
uc. No.
CONTRACTORS
ADDRESS
PPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
PHONE
DATE OF APPLICATION
ARRC HITECT
ENGINEER
LIC. NO,
SIGNS 6.00
PLAN CHECK FEE
SIGNS TRANS. 3.00
ADORESSs END' -
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
ITEMP. METER OR POLE INS. 15.00
ZIP
APLICANTS
ADDRESS , '
MOTORS SEE FEE SCH.
SERVICE CHANGECU�Uffl 10.00
'
LICENSED CONTRACTORS DECLARATION
CI .
-
^� 1982
I hereby affum that I am licensed under provisions of -Chapter 9
(commencing with Section 7000) of Division 3 of Ih¢ Business and
Professions Code, and my license is in full farce and effect. -
License Class Lie. Number
ISSUANCE DATE
BLDG. ELECT. PLG. ' MECH.
❑ ❑ ❑
Date Contractor.
j BUILDING PERMIT
INFORMATION
' OWNER -BUILDER DECLARATION
I hereby affirmthating r 1 am exempt from the Contractor's License
Law for the .fty owingreason.ch(See. Professions
a Business to
Code: Any city or county which requiresa permit to consuanc alter,
requires
MISO.'- REFER TO ORD
-. PERMIT ISSUANCE 6'00
VALUATION
l' O
$/FT,
ELEC. LONTR., LIC. NO.
ELEC.
TOTAL
ImpIOVC,den,OhSh,Orlepall any StNCtllr¢, p1131 to its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
R,• QOG
PERMIT TO
,�E
0 A
CITY. PLUMBING PERMIT FEE
the basis for the allege) exemption: Any violation of Section 7031.5
by any applicant for n permit subjects the applicant tau civil penalty
of not more than five hundred dollars (SS00).):
STORIES
TVPg CONSTR.
N
ALTER -DRAIN & VENT -WATER (EA.) 4.00
IsL as owner of the property, or my employees with wages as
sole compensation, will do the work, and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon, and who docs such work
himself or through his own employees, provided that such improve
Tents are not intended proffered forsale. If, however, the building
BACK FLOW PROTECT. DEVICE 2,00
O C. GROUP
^
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4,00
FIXTURES,- PER TRAP 4.00
GAS-EA.SVSTEM-11NC.40UTLETS 4.00
SO. FT. FLOOR AREA
fi
TOTAL ACREAGE
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im
purpose of sale.):
❑ 1, as owner of the property, am exclusively contracting with
V
GAS - EA. SYSTEM -OVER 4 (EA.) 1.00
BUILDING USE
RES IND CN PB O,M1er
❑ �❑ 0
uIS
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 MA.) 1.00
Ile? ,1,
Ile contractors to Construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon, and who
ASSESSORS PARCEL NO.
s such projects with a contraots) licensed pursuant m
contracts for d
the Contractor's s Lic¢nse Law.
❑ l am exempt under Sec. ',B.&P.C. for this
D'aon
r Own
`�]( E
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 4.00 '
WATER SYSTEM - 4.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
WORKER ; A fGtARAT1oN
I hereby affirm that I have a certificate ofconsent to self -insure,
or a certificate of Workers' Compensal ion Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof (Sec. 3800, Lab 0.
Policy No. -Company
❑
❑ Certified Copy is filed with the city inspection division.
Applicant
MISC. - REFER TO ORD.
FIRESPRINK
Y N
ENERGY T24
Y ❑ No
CERTIFICATEOF EXEMPTION PROM WORKERS'
COMPENSATION, INSURANCE
(This section need not be completed if the permit is for one
PERMIT ISSUANCE 6.00
FLOOD ZONE
A. L. u. c.
PLG, CONTR. LIC. NO.
PLG.
TOTAL
hundred dollars (S 100) or less.)
1 certify that in the performance of the work for which this per-
mit is issued, I shall not employ any'person in any manner sa as to
CITY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
��
'
become subject to the Workers' Compensation Laws of California.
Date - Applicant
NOTICIi TO APPLICANT: If, after making this Certificate of lix-
ALTER OR ADD TO MECH. 4.00
APPLIANCE 4.00
PLAN CHECK
FEE
en,ption, you should become subject to the Workers' Crunpcnsation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked
AIR HANDLING UNIT (TO 10A00C.F.M.) 3.00
AIRHANDLING UNIT(OVER 10=CF.M.) 5.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 2.00
HEATING UNIT (TO 100,000 B.T.U.) 4.00
I hereby affirm,that there is i construction lending agency for
30 ,Civ nonce of the work for hich this permit is issued IS¢c,
3 e lierlonnia
'
'MICROFILM
Lender's Name �� t
Lender's Address
HEATING UNIT (OVER 100;000 B.T.U.)7.50
ELECTRIC `
1 certify that I have read this application and one that the above
VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county
ordimmces and state laws relating to building construction, and
PLUMBING
BOILER -CO MP(3H.P.or100,0008.T.U.) 4.00
hereby enthorim represen tativesthis city enter upon the
above-mentioned property for inspection purposes.
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH,
MECHANICAL
(We) agree to save, indemnify and keep harmless the City of
MISC. - REFER TO ORD.
C
Cupertino against liabilities, judgments, costs and expenses which
st said City in consequence of the
ry a�m.c
PERMIT ISSUANCE - 3.00
CONST. TAX
o
k%%�
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL,gnatur
for UaI¢
OFFICE COPY
• CSERVICE�'
IOccupancy
lAddress
CENTRAL FIRE PROTECTION DISTRICT
3071 DRIFTWOOD DRIVE
SAN JOSE, CA. 95128
SINCE 1947 408.378-4010
Inspection Notice
Memo Form
Phone
14_1
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".17
.14
CFD 63984 - Patersons
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Memo To:
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CFD 63984 - Patersons
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CENTRAL FIRE PROTECTION DISTRICT Inspection Notice
3071 DRIFTWOOD DRIVE
SAN JOSE, CA. 95128 Memo pone
SINCE 047 4118,378 010
Occupancy11 Phone K, /(",/-,
Address
Memo To: A-�,�
14 1
I
CFD G3984 - Patersons
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CFD G3984 - Patersons
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