2526 APPLICANT TO FILL IN INFORMATION WITHIN RED, LINES - USE BALI- POINT PEN ON
BUILDING PROJECT I DENT[FICATI ON vER T BER
BUILDING APPLICATION & PERMIT ��
DR Ess
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL t.
O ER'S . PLAN CHECK VALIDATION
NAme Y. ELECTRIC PERMIT FEE
'CONTRACTOR'S a
NAMEIACE Mal OUTLETS-SWITCHES-RECEP 5.00/1.00
LI LIGHTING FIXTURES 5.00/1.00 -
roNT3CKV116K PPLIANCES-RESIDENTIAL 4.00
4C�TllFIRSTSTREET PANELS 5.00 . DATE OF APPLICATION
A CHITEC PLAN CHECK FEE P.C.NO,
DR SAN JOSE, CA 95110 .. steeds 6.00
rvGl
' .No. SIGNS TRANS. 3.00
ARCH.OR EN PERMIT VALIDATION
ADDRESS - SPECIAL CIRCUIT 5.00
zIP EMP. METER OR POLE INS. 15.00 G'
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00 • / , // /r�/
o o .LICENSED CONTRACTORS DECLARATION
rt D.v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of thea Business
and BLDG. ELECT. PLG: MECH.
F z Professions c Y hcen Li is in full f a�K.�+..•et ❑ ❑ ®.. ❑
z o m - License Cla�Lic.Number
Q w Date Contractor -
Q BUILDING PERMIT
¢ ¢ w ¢ OWNER-BUILDER DECLARATION ( INFORMATION
oA " MISC.- REFERTOORD -
X 3 LL ti I hereby atl'irn,that 1 ant exempt from the Contractors License VALUATION
FU04 Law for the followingmuson.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00 $/FT:
Code:Any city or county which requires a permit to construct,alter,
¢ 2 < o improve,demolish.or repair any structure,prior to its issuance also ELEC.CONTE. LIC.NO. ELEC.
0 w requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
o w m he is licensed pursuant to the provisions of the Contractor's License
rzi
Law(Chapter 9(crommencinµwith Section 7000)nf Division 3.1 the (/Jy/d IC,,
¢ Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE -
Or o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i3m by any applicant for a permit subjects the applicant toa civil penalty. ALTER-D. -WATER (EA.) -
of not more than five Iwndom dollars($500).): . -
❑ Las than
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,AR EA,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 re through his own employees, le.If.ed whet such impr(rv6
rants are not.ughintended oroffered for sale.If.however,111a,Ithe building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
Of improvement is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that lie did not build or im- - . .
RES IND CON PB One,
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-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors 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 contmctor(o licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/8:00 TRACT NO. PARCEL NO.
Cl I iln,exempt under Sea ,Ii."C.for this WATER HEATER W/VENT.
4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERSCOMPENSATION DECLARATION WATER TREATING-EQUIP. 4.00 '
Iherebyaffirm that l have a certificate of consent to selw-insure. ZONING ENG.SITE NO.
or pPay1 vnfeerrt1ttiifryic�attee of Workers'Compensation
Insurance,or a c•rw ificJ
I4rL2/GdV -L-a�vu Pl -
O ❑ Certified copy is hereby funukhed FIRE SPR INK ENERGY T24
pp Certifiedisfl�witb IhK lion division. MISC.- REFER TO ORD. v ❑ N❑ Y ❑ N❑
F m C�a' t PERMIT ISSUANCE 6.00 FLOOD ZONE A-L.u.c.
fL CERTH7[CATE OF I XEMPTION PROM RKERS'
LU > 70b1Pl!NSATION INSURANCE PLG.CONTE. LIC.NO. PLG. v El N❑ v ❑ N❑
CL 0 ('Phis section need nut be completed if file Permit is for One IOTA
Z) Z hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
_U_ H mit IS issued,1 shall not employ any person in any nnanner so as to
U become subject to the Workers'ContpensatiomLaws of California.
O w Dam Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
> N NOTICE TO APPLICANT: If,after making This Certificate of Ex-
F ? empfion,you should become subject to the Workers'Compensation APPLIANCE 4.00 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 10,000C.F.M.) 3.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.EM.) 5.00 SEISMIC FEE
1 hereby affirm it,., rhere 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.). H EATING UN IT ITO 100,000 B.T.U.) 4.00
Lender's Name HEATINGUNIT(OV ER 100,000 B.T.U.)7.50
Lender's Address 'ELECTRIC.
I certifythat 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 bounty BOILER-COMP13 H.P.or 100,000 B.T.U.) 4.00 PLUMBING10 Inc
ordinances and state laws relating to building construction, and '
hereby authorize representatives of this city to enter upon the BOILER-COMP [Over 100,000 BTU)SEE F E E SCH. MECHANICAL
above-mentioned property for inspection purposes,
(We) agree 10 save, indemnify and keep harmless the Cry of MISC.- REFER TO ORD. -
t 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 -
ng of t is ,c it. - MECH,CONT. LIC.NO. MECH.
TOTAL TOTAL
Or Applicant/Cm, :for LC
OFFICE GQPY