3341 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL-POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION R MSER
BUILDING APPLICATION•& PERMIT j�
A ORE55
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 4{
OWNERS 00 4)c - - FLANCHECK VALIDATION
AME TY. ELECTRIC PERMIT FEE
CONTRACTORS /. UTLETS-SWITCHES-RECEP ' 5.00/1.00
A-A.A.ACFG N t' LIGHTING FIXTURES 5.00/1.00
ADD
rGo oil APPLIANCES-RESIDENTIAL 4.00
So. FIRSTSTFtFF-TPANELS 5.00 DATE OF APPLICATION
ARCRrtECT PLAN CHECK FEE P.C.NO.
0R Ii,}AN JOSE, CA 95110. stens 6.00
NGI
.NO. SIGNS TRANS. - 3.00
AARCH.OR DDRESS EN SPECIAL CIRCUIT 5.00 'PERMIT VALIDATION
ZIP EMP. METER OR POLE INS. 15.00
APPLICANT$
ADDRESS MOTORS SEE FEE SCH.
SERVICECHANGE 10.00
w o o LICENSED CONTRACTORS DECLARATION '
a u 1 hereby affirm Our 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
N z w (commencing with Section 7000)of Division 3 of(he Business and
Q c BLDG. ELECT. PLG. MECH.
Hoz Professions Cod J e is in full f d effect. '
o z o License Clas+�7`mn Numb ❑ ❑ ❑ ❑
F 0 H j Date Cle.Ni r b���o
sc m BUILDING PERMIT
W 0 n < OWNER-BUILDER DECLARATION INFORMATION
F ; m I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
u Law forlhe following reason, 7031.5,Business and Professions PERMIT ISSUANCE 6.00 VALUATION $/FT.
Ino Code:Any city orcounty which requires a permit(o construct,alter,
ac 2 ¢Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO, ELEC.
wO LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
m he is licensed pursuant to the provisions of the Contractor's License
H 2 a Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe -
i 4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
,-m the basis for the alleged exemption.Any violation Of Section 703 L$ STORIES TYPE CONSTR.
i ; by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more titan five hundred dollars(8500).):
❑ 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 F IXTUR ES-PER TRAP 4.00 SO,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided that such improve-
mentsarenotintendedoroffered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner,
builder will have the burden of proving that he did not Build or int, GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
prove for purpose of sale.). RES IND CON PB Other
❑ I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the pmject,(Sce.7044,Business LAWN SPRINKLERS-I INC 5 V.8. 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(EA.) 7.00
contracts for such projects with a contractogs)licensed pursuant to
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
❑ lam exempt under Sec.-,BAP.C.bnthis WATER HEATER W/VENT 4.00
reason
Date owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
` WORK E RS'COMPENSA'fION DECLARATION WATER TREATING EQUIP. 4.00 '
1 hereby affirm that I have a certificate of consent to self-insure. ZONING
or o certificate of Workere'Compensation I sur cc.or a certified ENG-SITE,NO.
Y e f
By
P n
Y-
Q erI cop I chy l'unushcd. FIRE SPRINK ENERGY T 24
Z p pplicanttifieyelspy�fled with the city inspection division. MISC.- REFER TO ORD. Y❑ ME] Y ❑ N[:)I
CC CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE - 6.00 FLOODZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d 0 (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
0 Zhundred dollars IS 100)or less)
C.) O I certify that in the performance of the work for which this per. OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
Date Applicant BUILDING
M ALTER OR ADD TO MECH. 4.00
'} N NOTICE TO APPLICANT: If,after making this Certificate DI'.Ex.
F 2 emplion,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
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER 10=C.F.M.) 5.00 SEISMIC FEE --
I hereby affirm (hat there is a construction lending agency I'nr EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) .4.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)Lender's Address ELECTRIC
I certify that l have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
. infornmion is correct, I agree to comply ankh all city apd county PLUMBING
ordiwmces.and state laws relming to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER'COMP (over logOOOBTU)SEE FEESCH. MECHANICAL
above-men(ioned property for inspection purposes.
(We) agree to save, Indemnify and keep hartiless the City of MISC.,- REFER TO ORD.
rano against liabilities,judgments, costs and expenses which CONST.TAX
may n any waycruc against said City in c uence of the PERMIT ISSUANCE 3.00
gran gof is pet it, MECH.CONT. LIC.NO. MECH,
TOTAL TOTAL
' gn' r Ian t ate
OFFICE COPY