10021 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT 1 DENTI FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 0
ADDRESS BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
21
�/ OWNER'S PLAN CHECK VALIDATION
'''X\ N ME ,Q y� j/�'/- A ELECTRIC PERMIT FEE
Q C / V�1 �'C► PHONE ivo
CONTRACTOR'S OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
LIC.NO LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'SAPPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT S.QQ PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00
APPLICANT'S Estate ot Charles Cosser MOTORS SEE FEE SCH.
ADDRESS 4
2 N.2nd St. #1400 San Jose SERVICE CHANGE 20.00
0 0 o ENSED CONTRACTORS DECLARATION TEMP.P044QV ICI:; 30.00
w
Q v v 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
N Q a (commencing with Section 7000)of Division 3 of the Business and BLDG. E C PLG. MECH.
F z)z Professions Code,and my license is in full force and effect. ❑ ❑ ❑
Z o co - License Class Lic.Number
o N F Date Contractor
Q Y I' B ILD11148 PERMIT
¢ ir w ',1C) OWNER-BUILDER DECLARATION INFORMATION
X 3 LL N 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- T3EPkATO ORD
F w o¢ Law for the following reason.(Sec.703 1.5,Business and Professions PERMIT IS UANCE 10.00 VALUATION $/FT.
N N Code:Any city or county which requires a permit to construct,alter,
Qim�'rove,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO ELEC. //r�1y
w a ¢ requires the applicant for such permit to file a signed statement that TOTAL _% R IT TO
a w N he is licensed pursuant to the provisions of the Contractor's License
Z > Law(Chapter 9(commencing with Section 7000)of Division 3 of the
- Q Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
x o
¢ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a 3 �2 by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).1'
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 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. 5.00
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 5.00 SQ.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS_EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Ocher
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
as owner of the property,am exclusively contracting with
kens d contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions CodeThe Contractor's License Law does 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 contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ 1 arjexe,npt under Sec ,B.&P.C.for this WATER HEATER W/V ENT 6.00
Owner"� Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is tiled with the city inspection division.
O Applicant MISC.- REFER TO ORD. Y [:] N Y [:] NE]
CC CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d 0 (This section need not be completed if the permit is for one TOTAL YE] N❑ YE] N
Z) Z hundred dollars I$100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
U_ mit is issued,I shall not employ any person in any manner so as to
0 become subject to the Workers'Compensation Laws of California
O a Date_ _Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} [n NOTICE TO APPLICANT: If,after making this Certificate of Ex-
Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10PMC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC SZ�v
1 certify that 1 have read this application and state that the aboveVENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county BOILER COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOI LER-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 consequence of the PERMIT ISSUANCE 10.00
gra ing of tNs permit. MECH.CONT. LIC.NO. MECH.
j�PXe k>�o P M�t r�pl" TOTAL TOTAL
Signaturddf Applicant/Contractor Date
OFFICE COPY