2894 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PE MIT R
BUI LDI NG PROJECT I DENTIFICATe ION
RuuLE.1, gppLICATIONI& PERMIT 894
RE55
B I ING -ELECTRICAL'-PLUMBING-MECHANICAL
OWNER'S d PLAN CHECK VALIDATION
N E PH 6V66 q/ QTY. ELECTRIC PERMIT FEE
VNONTRAC ORS % _
NAME OUTLETS-SWITCHES-RECEP 5.00/1.00
ACE trc N LIGHTING FIXTURES 5.00/1.00
coNr� B APPLIANCES-RESIDENTIAL 4.00
AoolVs ,
AUFIRST STMOr PANELS 5.00 DATE OF APPLICATION
A C 00 PLAN CHECK FEE P.C.NO.
°NGSAN JOSE, CA 98110 SIGNS 3.00
�.No. SIGNS TRANS. 3.00
ADDRESSE - SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
atP TEMP. METER OR POLE INS. 15.00
AwuESMOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
o ¢ i
Foo LICENSED CONTRACTORS DECLARATION
au u I hereby aflirn that I ala licensed under,p...Won,of Chapter9
Z ISSUANCE DATE
vi a w (commencing with Section 7000)of Division 3 of the Business and e 1 BLDG. ELECT. PLG. MECH.
E. y z Professions y licence is in full Lary,rq�. t ] ❑ ❑ ❑ ❑
otomo License Cla Cin. � O /
m H J Dalc onlact.,mclor .�j�.Q
¢ ¢ Er w a OWNIi R-B UILDIiR DECLARATION BUILDING PERMIT
w ;" m I hereby affirm that I am exempt from the Contractor s License MISC. - REFER TO ORD INFORMATION
w o v, Law for the following reason.(Sec.7031.5.Businessand Professions VALUATION S/FT.
r - PERMIT ISSUANCE 6.00
Code:Any city sh wr rep which requiture permit to bnsuanc el@n
rt ar Q improve,demolish,o!repair any structure,prior to Its issuance,also ELEC.CONTR. LIC.NO. ELEC.
o u requires the applicant for such permit to file a signed statement that TOTAL
u w m m he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
z <
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
z 0 Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ F pN the basis for the alleged exemplion.Any violation of Seek....703 L5 STORIES TYPE CONSTR.
a3 - by any applicant for a permit subjects the applicant toa civil penalty
of ALTER-DRAIN&VENT-WATER (EA.) 4.00 '�-
mol..tore than five hundred dollars($500)J'.
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECTDEVICE
their sole compensation,will do the work,and the structure is not . 2.00 OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 4.00
Code:The CRntamlor's License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 so.FT.PLooR AREa TOTAL ACREAGE
. himself ents re n not
into his own employers.provided thus such improve-building
mimprovment is auld within tuneed year
If,mpletion the the owner-
GAS-EA.SVSTEM-1 4.00
or improvement Is sold within one year of completion,the owner-
builder will have the ale), of proving that he did not build or ins, GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
prove for 1.aso neeose of sale.). INDUSTRIAL WASTE INTER. RES IND CON PB Omer
❑ L as owner of the property,am exclusively'contracting B with 20.00 ❑ ❑ ❑ ❑ ❑
licensed cpnractod to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and IPro cessions Code:The Contractor's License Law does not apply
to an owner at property who builds or improves thereun.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractoll sl licensed pursuant to
the Contractor's Licence Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.fm this
reason WATER HEATER W/VENT 4,p
Date owner • WATER SYSTEM 4.00 ACC.OATE ACC.FILE NO.
WORK ERS'COM PENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that 1 have a certificate of consent Wself-insure, _
or a certificate of Workers'Compensation lnsrrance,or a ecr ifiud ZONING ENG_SITE NO,
rop hereof • j8Q Lam C.).
O of _ y-
ertlfieJ copy¢ sere y fumishe .
Z Z j4 C',ifted sled will inF lection division. "MECH. 4.00
FIRE SPRINK ENERGYT.24
1-- O A Pham a `��. MISC.- ORD. v ❑ N C Y ❑ N�
CC Lo CER'I'IEICATEoPIixEMPTIONI RO\I RKFRS' PERMIT I6.0 FLOODZONE A.L.U.C.
L J > COMPENSATION INSURANCE PLG,BON I H. LG.
d O (This section need not be completed if the permil is lav one TOT Y N Y 11 N❑
� Z h inured dollars IS IOD)or less.)
0 O 1 certify that in the performance of the work for which this per.
LL 1- mit is issued, I shall not employ any person in any manner an as to QTY. FEE FEE SUMMARY
Ow become subject to the w'orkers'Compensation Laws of California.
Q. Dec Applicant ALTER Oq,Qp BUILDING
} Z NOTICE '1 O APPLICANT: If,after making this Certificate of Ex-
- emotion,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions M the Labor Code, you must forthwith comply with
U
"'all provisions or this permit shall be decreed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 3.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IOAOOC.EM.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency or EXHAUST HOOD(WITH DUCT) 2.00
the performance of the 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
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify that l have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
information n correct. I agree ti comply with all city and county' PLUMBING
ordinances and stag laws relating to is building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
above- arathoric representatives ec this city es enter upon the
above-mentioned property for inspection peploses. 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.
Cupertino against liabilities,judgments, costs and expenses which p ISC.- ISSUANCE CONST.TAX
'p,y anway,' accrue against said City i consequence of the 3.00
his c 't. MECH.CONT. LIG NO. MECH.
DTAL TOTAL /`�ApplicantlCpntmctor Da r
OFFICE COPY