3339 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
.BUILDING PROJECT IDENTIFICATION 6/PE/RMINUMBER
emaoeuc - BUILDING -EL
CTRIICAL-NLSL B NG-MECHAN 3339
s r 1
OWNERS - - PLAN CHECK VALIDATION
1�«yE' TV. ELECTRIC PERMIT FE
I
• :I_
S PII
r' 6IaR' OUTLETS-SWITCHES-RECEP 5.00/1.00
PLI�IKgINCi . LIGHTING FIXTURES 5.00/1:00
OONTPA t js - PPLIANCES-RESIDENTIAL 4.00
/ A ES
PANELS 5.00 DATE OF APPLICATION
2�IM. First Street SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER .San Jose, CA 9511
Tele 110 SIGNS TRANS. 3.00
ARC
H:OR ENG. - - PERMIT VALIDATION
ADDRESS _ SPECIAL CIRCUIT - 5.00 I•
ZIP EMP.METER OR POLE INS. 15.00 ^ ///`_��
�.� ADDRESS - -- MOTORS -SEE FEE SCH. a
ADDRESS e
SERVICE CHANGE 10.00 p/ / •�(
ro a LICENSED CONTRACTORS DECLARATION O/� 1�
e[ w - - . _
¢ v�i I hercl+y affirm tlml I am licensed under provisions of Chapter 9 - ISSUANCE DATE
H z w (commencing with Section 7000)of Division S of he Business and
y ¢ y BLDG. ELECT. PLG.1 MECH.
r z Professions Co a cense is in full fO .. ❑ ❑
oz=C License Class _Lia Numbe
m Date Contractor -
a S, Y < h BUILDING PERMIT
M
c0 i U OWNER-BUILDER DECLARATION - INFORMATION'
.i w H I hereby affirm Thal I am exempt from theContractor's License MISC.- REFER TO ORD
VALUATION SIFT.
H : o ¢ Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00
Code:Any city or County W hiCh m(ptireb a permit to conslruaL altar,
¢ to improve, or repairany structure,prior to its issuance,also ELECT CONTR. LIC.NO.BE 4 ELEC.
iO LL requires the applicant for such permit to file a signet)statement that TOTAL PERMIT TO
w9 he is licensed pursuant to the provisions of the Contractor's License PG U�q�
r Z a La.(Chapter 9(commeneing with Section 7000)ofDivision 3 of the
f 4 G Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢f $ the basis for the alleged exemption.Any violation of-Section 7031.5 STORIES TYPE CONSTR.
a3 � by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five:hundred dollars(5500).1:
❑ I,as owner of the property,or my employeeswith wag+.'sas BACK FLOW PROTECT. DEVICE, 2.00 DCC.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 docs such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself.^)through his own employees.provided that such improve.
of intended or offered for sale.if,however,the building GAS-EA.SYSTEMLI INC.40UTLETS 4.00
- hent is sold within one year of completion.the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
u Llfr will have the burden of proving that he did not build or int-
i prove for purpose of side.)., I INTER. RES IND , CON FB Gum,
CI 1.as..net of the property,am exclusively contracting with 20.00 ❑ ❑ ❑ ❑ ❑
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 does not apply -
to'an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such projects with it contructv(e)licensed pursuant to
- ' the Contractor's License Law. SEWER-SANITARY=STORM 'EA.200ft/8.00 - TRACT NO. PARCEL NO.
1 ❑ I am exempt under Sec. ,B.&P.C.fir this WATER HEATER W/VENT - '4-g
reason
Date Owner WATER SYSTEM PAILJ 4.00 ACC.DATE ACC.FILE NO,
WORKHRS'COMPENSATION DECLARATION'
WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate ofconsent to sell-insure.
or'a certificate of Workers:Compensation runce,or a ce ified ZONING ENG.SITE NO.
�y'p1]�Yy r f b ..1.
❑- r ed copy Is er y furnished. - { 11 et )
z Z Btl, c filed with t y tttiop division. 01 FIRE SPR INK ENERGY T.Y4
F O pplic;utt �T' IT O i _ MISC.- REFER TO ORD, '- Y❑ N❑ Y ❑ `N❑
w �, PERMIT ISSUANCE 6.00,;,,/7,
� - CIiRTIPICA'1'Ii OF GXIiMPI'ION PROM OItRIiRS' FLOOD ZONE A.L.u.a
IL _0 COMPENSATION INSURANCE' - PLG.CONTR. LIC.NO. PLG. -
1 (This section need nom
t�be completed if the pern+it is for one TOTA Y E] N❑ V❑ N❑
Z (This
dollars(F100)or less.)
U O 1 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 oat employ any persodio any manner so as to
Q W become subject to the Workers'Compensation Laws of California.
Date licunt BUILDING
a ' pp ALTER OR ADD TO.MECH. 4.00 -
} N NOTICE TO APPLICANT: If,after mu king(Itis Cert it teat,of I>x- _
I- Z emplion,.you should become subject to ro
the Workers'CompeWion APPLIANCE - 4.00 - PLAN CHECK'
provisions of the labor Code, you must forthwith comply with .FEE .
L) .such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY � AIR HANDLING UNIT(OVER I0,000C_.EM.) 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,Cis,C.), HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 '
Londer's Address ELECTRIC
I.rertify that l have read this application andsmte that the abuse VENTILATION FAN (SINGLE) 3.00
int. "'+Nm is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 700,000 g.T.UJ 4.00 PLUMBING
Wnd state laws relating Io building construction, qnd
nee representatives of this city to enter upon the BOILER-COMP IOve�100,000 BTU)SEE FEE SCH. 4 MECHANICAL
•,;hoed 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 consequence of the PERMIT ISSUANCE 3.00
granling of this permit. MECH.CONT. ' LIC.NO. MECH.
. rorAL TOTAL YA '
I'Signature of Applicwd/Contractor UcluIn
OFFICE COPY _ -
\ .