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3084 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL_ POINT PEN ONLY f BU I LOING PROJECT I DENTIFICATION' PER N BUILDING APPLICATION & PERMIT 84 DREss `! r BUILDING-ELECTRICAL-PLUMBING-MECHANICAL PLAN CHECK VALIDATION rvAME TY. ELECTRIC PERMIT FEE C, I �~ NAMERAC*DR's /gypE OUTLETS-SWITCHES,RECEP 5.00/1.00 ACLc.ND. LIGHTING FIXTURES 5.00/1,00 70N ' APPLIANCES 4.00 D - AU PANELS - 5.00 DATE OF APPLICATION A EII FIRST S=EEr PLAN CHECK FEE P.C.NO. 0E IN JOSE, CA 98110 SIGNS 6.00 arvo. SIGNS TRANS. 3.00 AARCH,OR GGRESS E SPECIAL CIRCUIT 5,00 PERMIT VALIDATION ZIP EMP.METER OR POLE INS.- 15.00 APPLICANTS MOTORS SEE FEE SCH. ADDRESS - SERVICE CHANGE 10.00 'W o O LICENSED CONTRACTORS DECLARATION u u ,I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE ,FAQ y (Commencing with Section 7000)of Division 3 of the Busines nd BLDG. ELECT. I PLG. MECH. F D i Professionse, y license is in fall forpf'.1�T z o h - License CIaS` _Lis.Nuntber-0[.Q_ ❑ ❑ ❑ ❑ o r D Date-Contractor ¢y s BUILDING PERMIT ¢ Be w OWNER-BUILDER DECLARATION INFORMATION a0a ' MISC.- REFER TO ORD X ; vFi 1 hereby affirm that I am exempt from the Contractor's License Fao ¢ Law for the following reason.(See.7031.5,Businessand Professions PERMIT ISSUANCE 6.00 VALUATION Code:Any city or county which requiresa permit to construct,alter, ¢ > improve,demolish,or repair an structure,prior to its issuance,also ELEC.CONTE. LIC.NO. Q 4 p P P' Y p ELEC. O I,requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO n w$m he is licensed pursuant to the provisions of the Contractor's License tz> Law(Chapter 9(commencing with Section 7000)o f Division 3 of the - 5 i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE ¢ F S the basis for the alleged exemption.Any violation of Section 7031.5 STORIES- TYPE CONSTR. d ; _ by any applicant for a permit subjects the applicant ma civil Penalty ALTER-DRAIN -WATER (EA.) 4.00 of not more than five hundred dollars(4500).): _ ❑ I,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,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 SG.FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that such improve- mestsare not intended oroffered for sale,If,however,the building GAS-EA.'SYSTEM-11NC.40UTLETS 4.00 or improvement is sold within one year or completion,the owner- GAS-EA.SYSTEM-OVER 4 MA.) 1.00 BUILDING USE builder will have the burden of proving that he did not build or im- RES IND CON PB Omer prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00' ❑ ❑ ❑ ❑ ❑ I,as owner of the property,am exclusively contracting with licensed contractors to construct the Project(Sec.7044,Business LAWN SPRINKLERS-I INC 5 V.B. 5.00 ASSESSORS PARCEL NO. and Professions Code:The Contractor's License Law does not apply to an owner of property who builds or improves them...and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 contracts for such projects with a contraelorts)licensed pursuant In the CUntractor's License Law. SEWER-SANITARY-STORM EA.200ft/B.00 TRACT NO. PARCEL NO. ❑ lam exempt under Sec.-.B&P.C.for this WATER HEATER W/VENT 4.0 reason 9140 Date Owner WATER SYSTEM 4.00 ACC.-DATE ACC.FILE NO. WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00 I hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE N0. or a certificate of Workers'Compensation I or c or a certified ). 0 ❑,Certified Copy l y umished. ,O FIRESPRINK ENERGY T-24 Z ZCertified p is tiled wi 'i d sp tion division. MISC.- REFER TO ORD. Q pplmanl -- Y [:] N❑ V ❑ N[] � T CERTIFICATE OF EXEMPTION FROM KERS' PERMIT ISSUANCE 6.0 FLOODZONE A.L.U.C. LU >_ COMPENSATION INSURANC. PLG,CONTH. sec.No. PLG.CL o (This section need not he completed if the permit is for one IOTA �C�.J Y E] N❑ Y ❑ N❑ D Z hundred dollars($100)orless.) 0 O I certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY LL F mit is issued,I shall not employ any person in any manner so as to U become subject to ore Workers'Compensation Laws of California. y Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING W NOTICE'1'0 APPLICANT: If,after making this Certificate of Ex- L.. ? emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK provisions of the Labor Code, you must forthwith comply with FEE CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MOC.F.M.) 3.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MOC.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.C.L I HEATING UNIT(TO 100,000 B.T.U.) 4.00 Lender's Name HEATI NG UN IT(OV ER 100,000 B.T.U.)7.50 ELECTRIC Lender's Address I certify that l 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(3H.P.or 100,000B.T.U.) 4.00 epin hereby authorize representatives of this city to enter upon the BOILER-COMP Over 100,000 BTU)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 - may in any way accrue against said City in consequ ace of the PERMIT ISSUANCE 3.00 gr g this pen MECH.CONT. LIC.NO. MECH. ' TOTAL TOTAL Sig a of p ic / ractor Dale OFFICE COPY