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6987 APPLICANT TO FILL IN INFORMATION'VVITHIN RED LINES - USE BALL POINT PEN ONLY ` PERMITNUMBER BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT r AESS /�/�/�ness 2U QO $tE:{70f13 Cx+eeh B1Vd. BUILDING-ELECTRICAL-PLUMBING-MECHANICAL `6,98OER'S PLAN CHECK VALIDATION E Tishman Yd&bu& Creek OTY ELECTRIC PERMIT FEE IAn-dtedPNONE NAMEBAceons UTLETS-SWITCHES-RECEP 5.00/1.00 449.0 _ PIM r�' , uc.of LIGHTING FIXTURES 5.00/1.00 CONTRACTORS }� PPLIANCES-RESIDENTIAL 4.00 ADDRESS P.O.E= 2380 (415) PRONEPANELS S.00 DATE OF APPLICATION t _ OR SIGNS 6.00 PLAN CHECK FEE P.C.NO. t ENGINEER GE[L91@r.1.880. LIC.No. SIGNS TRANS. 3.00 ADDRESS ENPERMIT Kearny SPECIAL CIRCUIT 5,00 PERMIT VALIDATION t ZIP 941011 rrEMP.METER OR POLE INS. 15.00 ADDRESS MOTORS SEE FEE SCH. 0 ` P.O.Box 2380 SERVICE CHANGE 10.00 w¢ i P 3 w.,00 _ LICRNSIU CONTRA CUAATION 0 I hereby affirm that 1 am licensed under pruvisions ol'Chapter 9 ISSUANCE DATE < a w (commencing with Section 7000);of Division 3 of the Business and ti Q y H w z I mfessions Code,and my license is in full force and effect I%/ BLDG. ELT. PLG. MECH. i i o I en a Class_��_Lic Number�' ' ©._ ❑ Q H D t }q Contmnor - a x E /a4 • _ -.y ...xp.�. t BUILDING PERMIT ¢ ¢ ¢ OWNER-BUILDER Df:CLARA'TION - a o s o • - INFORMATION '- w ; a- N I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD ygLunnON 8/FT. -FuOQ Law for lire following reason:(Sce.7031.5,Business mill Professions PERMIT ISSUANCE 6.00 6. Q Cotte:Any city or county which vilifies a permit to Construct,alter, ELEC.CONTR. LIC.N0. ¢ ¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC. D¢ requires the applicant Tor such permit to file a signed Stalenent that TOTAL IL w m w he is licensed pursuant to the provisions of tire Contractor%License PERM T TO Hz> Law(Chapter 9(commencing with Suction 7000)of Division 3 ofthe ' a Business and Po,l'essions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE ¢ r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. OIL by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN Bi VENT-WATER (EA.) 4.00 of not more than five hundred dollars($500).): ❑ 1,as owner Of it,,properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS their sole compensation,will do the work,and the structure is not intended or offered for sale (Sec. 7044, Business.ad Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 Code:The Contractor's License Law does not apply to an owner of _properly who build,or improves thereon.and who due,Such work FIXTURES-PER TRAP 4.00 SU.FT.FLOOR AREA TOTAL ACREAGE . himself ur through hie own employee,,provided that such inprtovo- . nuns are not intended or offered for sale.It,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00 or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE builder will have the burden of proving that he did not build or ins I' RES IND_E El C N PB Otner prove 1,as owner of the.P x INDUSTRIAL WASTE INTER. 20.00 en d as owner of the property,lint erojecty Sc contracting with 0 ED licensed contractors to construct (lie project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 A55ESSo P RCEL No. and Professions Code:The Contractor's License Law does riot apply to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 'contracts I'orsuch projects with a contractoos)licensed pursuant to The C'ontruclor's License Liw, SEWER-SANITARY-STORM EA.200ft/8.00 TRACTNO. PARCELNO. 0 1 ant exempt under Sec. B,&P.C.I'.,this WATER HEATER W/VENT 4.00 reason Owocr - Date WATER SYSTEM 4.00 ACC.DATE ACO.FILE No. 4 WAORKFRS'COMPFNSA'1ION DECLARATION WATER TREATING EQUIP. 4.00 11-hereby:a0rm4hat-1-hive a certificate of Consent to selLinsure. .' or a'certificate of Workers'Compensation Insurance,or a ce Hified ZONING ENG.SITE NO. copy thereof(Sec,3800 1 ab.C.) Policy No.}���/����p�� ty � Q CC Wgu _ l{{ILA furnished - .;,--y ---- •ys" T ' FIRE$PRINK ENERGYT Y4 2'Z of Certified copy s fihd`with the city inspection division. MISC.- REFER TO ORD. F.0 Appicam r EJ N� Y [] N� � N CER'TIFICAT I!OF FXFMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE ' A.L.u.C. LU COhIPI:NSATION INSURANCE PLG.CONTR. LIC.NO, PLG. V� NE] VO N(_]� 2 This sect ion need not be completed if the permit is for one TOTAL hundred doll...($100)or less.) _ U 0 1 certify that io the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY LL H ntit is issued,I shall not employ any person in any manner so as to - O-W become subject totire Workers'CompensationLaws ofCalifornia BUILDING Wte- Date Applicant ALTER OR ADD TO MECH. 4.00 } U1 NO'TIC17 TO APPLICANT: If,after making this Certificate of Ex- F Z ctnption,you Should become subject to the Workers'ComPcnsution APPLIANCE - 4.00 PLAN CHECK provisions 61' the Labor Code, you must forthwith comply with FEE U such provisions or this permit Shall be deemed revoked, AIR HANDLING UNIT(TO 10=C.F.M-) 3.00 CONSTRICTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE I hereby infirm Dud there is . construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00 the ped.unance oPOtc work for which this permit is issued(Sec. MICROFILM 3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.1 4.00 Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 Lender's Address ELECTRIC I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 I •\ information is correct.I agree to comply with all city and co , BOILER-COMP(3 H.P.or 100,0008.T.U.1 4.00 PLUMBING ordinances and state laws relating to building construction, and hcruo'y autltori/e representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL above-mentioned property for inspection perpow,s. (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against liabilit ,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX may in any way, aeon against said Cily in consequence of the gen!-g of this pen it. // / MECH.CONT. LIC.NO. MECH. y/X( TOTAL TOTAL (nA Sign 1 are of Aflplicant Contractor r ate INSPECTOR COPY -