6955 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
BUILDING PROJECT IDENTIFICATION APPLICATION 81 PERMIT
ADDRESB'ILDINS
- _ - 6955
ADOREss
2040OMariani AV. BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S / - PLAN CHECK VALIDATION
NAME - , QTY. ELECTRIC PERMIT FEE
SYVA _ PHONE
CONTRACTOR
NAME UTLETS-SWITCHES-RECEP 5.00/1,00
West Coast Mechanic&1NO. 443481 LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S p,O.BOx 4702 APPLIANCES-RESIDENTIAL 4.00
ADDRESS
Hayward, 94540 P.ONL415/783-28 0 PANELS 5.00 DATE OF APPLICATION
ARCHITECTSIGN$ 6,00 PLAN CHECK FEE P.C.NO.
On
ENGINEER
sec.NO, SIGNS TRANS. 3.00
ARCH Ess ENG, SPECIAL CIRCUIT S,DD PERMIT VALIDATION
IIP FEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS'PLICA
SERVICE CHANGE 10.00 ?�_-
o m i i J
I Foo LICENSED CONTRACTORS DIiCLARA'I'ION
a v u I hereby affum That I am licensed ander provisions of Chapmr 9 ISSUANCE DATE
1 m G n (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT, PLG. MECH.
F w Z Professions Code,am{{��t�yv,,II sense is in full force yytq f
z o m- License Class fz.J.O U, Number�9 `J-O.L� ❑ ❑ ® ❑
D N F w nate-1-2-�1-7_/-g4-cnlltraetnlWest Goast-Me ha teal
a a, s - BUILDING PERMIT
M a w a OWNIi R-HUILDfiR DECLARA'T'ION INFORMATION
0 - MISC.- REFER TO ORD
E
3 LL H 1 hereby collo that 1 um exempt from me Contractors License
LLo ¢ Law for mcfolluwing reason fScc.7031.5.Businussund Professions PERMIT ISSUANCE vAWAnON
� - J Code:Any city or county which requiresa permit to construct.alter,
6.00
¢ ¢ ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n w m he is licensed Pursuant to the provisions of the Contractor's License
Fz >
Law(Chapter p(commencingwith Section 7000)ofDivision3ofthe 1046"-
- a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢r p the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
5,;w- by any applicant for a permit subjects the applicant loa civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(5500).):
❑ 1,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'Fhe Contractor's 1-icense Law does not apply to an owner of
property who builds or improves thereon,and who does such work 1 FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees.provided that such ire building
ments mselfo not intended his or offered fees provided thacr,thcmpro ng GAS-EA.SYSTEM-1INC.4OUTLETS 4.00
r improvement is sold within ono year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
provefor purpose ofsale.). INDUSTRIAL WASTE INTER. 20.00 RES IND CON PR Omer
❑ 1,as owner of the Property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to Construct the project(Sec 7044,Business LAWN SPRINKLERS-1 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.) 1.00
contracts for such projects with a contractor/sl licensed pursuant d,
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
❑ lam exempt under Sec. .B.&P.C.for ml5 WATER HEATER W/VENT 4.00
Owner Dam WATER SYSTEM 4.00 ACC.DATE Ace.FILE No.
WORKERS'COMPI.NSA'f ION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that 1 have a Certificate of concent to self-insure. ZONING ENG.SITE NO.
or,a certificate of Workers'Compensation Inn
surace,m a Certified
Corr mereq1�L$ 3 �n. ).
Policy No.�N L'! ri m an d.C].f1C_C
Q ❑ Cetlilied[oI is he fumisheJ. FIRE SPO INK ENERGYT-24
Z Z }(17 Cerl il' a is cJ-with t c - if io isiun. MISC.- REFER TO ORD. y ❑ N❑ v ❑ N❑
Q Applicant
N CERTIFICA'I R OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 (1 00 FLOOD ZONE A.L.U.C.
W >_ COMPHNSAT10N INSURANCE: PLG.CONTR. � LIC.NO. PLG.
Q. O 1"Fhis xection need not be completed if the permit is for one West Oast Meeh. 44348 TOTAL V❑ N❑ Y ❑ N❑
D Z hundred dollar,(SI00)or less.l
U O 1 certify that in Oro pafoomance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL P mit is issued,1 shall not employ any person in any manner so as Lo
O W become subject to the Workers''Conlpensution Laws of California. BUILDING
Date Applicant ALTER OR ADD TO MECH. 4.00
} N NOTICE-'f0 APPLICANT: If,after arcking this Certificate of lix-
Z cmption,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 provisimssor this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1Q000GF.M.) 3.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10OWC.F.M.) 5.00 SEISMIC FEE
I hereby of F.... that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the pertormunce of the work for which this permit is issued(Sea MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's N.Irc HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lenders Address
I certify mat 1 have read this application and State that the above VENTILATION FAN (SINGLE) 3.00
information is correct. 1 agree to comply with all city and county BOILER-COMPO H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building Construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,0000TU)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 an expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any y accrue against Said in sequence of the
grmltin,of if permitMECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
atur I Applica tractor, a
OFFICE COPY