4803APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILD ING PROJECT, I DENTI FICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
4803
aD,Lm G
ADOREss
Ia
10051 Psadena Ave,
OWNER'S
NAME Bill Kinst
CITY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
Rolland Sharpe PHONE
caoRs
NAME
NAVE
OUTLETS - SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
AsinaC Corp. UC.No. 247722
CONTRACTOR Newark; CA. 94560
ADDRESS
APPLIANCES - RESIDENTIAL 4.00
PANELS 5.00
7855 Enterprise Dr:HONE 796-8311
DATE OF APPLICATION
ARCHITECT
OR
ENGINEER
_ LIC. No,
SIGNS 6,00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARC" ORENG.
00 CIRCUIT S.
PERMIT VALIDATION
TEMP. METER OR POLE INS, 15.00
ZIP
MAY $ OS
APPLICANTS
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSED CON TRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter
(commencing with Section 7000) of Division 3 ol'the Business and.
Professions CCrlk3rsd`rrl26cemw rs in full force24"77`2t2
Lic. Number
License Class.
ISSUA GEDATE
-
BlL¢¢G
M)
u
6 f��. G5ECffy
r t.11
u
efyytl MECH
u
Date Contractor
BUILDING PERMIT
OWNER -BUILDER DECLARATION
1 hereby nolle that I :un exempt from the Cnnt rectors License
CLaw ode: Any citylowingrcy whichee. 7031.5,Busin bend Professions
a tune p riot o its issuance.
Code: Any c olish cOr rep it any Structure. . ,so ellFLED.
improve. demolish, or repair any emit core, prior to its issuance, also
thedp orma for such revisit to GIC a signed Cont act.,', i that
requires licensed
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter9 (commencing with Section 7000)of D ivision30l the
Business andndProfessions Code) or That he is cxelnpt therefrom and
INFORMATION
' MISC.- REFER TO ORD
VALUATION
PERMIT ISSUANCE 6,00
CONTR. LIQ NO.
ELEC.
TOTAL
PERM I 'TO
OTV. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any viola inn ul Sec1im17031,5
ALTER -DRAIN & VENT -WATER (EA.) 4.00
by any applicant for a permit subjects the aprlicanl to a civil penalty
of not more than five hundred dollars (S500).):
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is nut
BACK FLOW PROTECT. DEVICE 2.00
oce. cflouP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
intended or offered for sale (Sec. 7044. Business and Professions
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
TOTALACREAGE
himself or through his own employees, provided that such improve.
ments are not intended or offered for sale. If, however. the hudding
GAS-EA.SYSTEM-11NC.4OUTLETS 4,00
or improvement is sold within one year of completiontile' owner-
builder will have the burden of proving that he did ml build ur im
prove for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Sec. 7044. Business
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon, and who
GAS - EA. SYSTEM -OVER 4 IEA.) 1.00
BUILDING USE
RES IND CON PD Omer,
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a cuntractorls) li cased pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
WATER HEATER W/V ENT 4.00
❑ 1 am exempt under Ser. , BAP.C. for Otis
reason
She Owner
WATER SYSTEM 4.00
ACC. DATE
ACG FILE NO.
WATER TREATING EQUIP. 4.00
WORK(! RS'COMPI!NSAT' ION DECLARATION
I hereby affirm that 1 hava I certificate of consent to self-instue
or a certificate of Workers' C-mn...IRrg IK2.rirun6y31 niRed
copy thereof (Sec. 3900, Lab.C.).
ZONING
ENG. SITE NO.
Policy No. _Company-ROjA8-1-In'Bur-an@e
FIRE SPRINK
Y [:]N F]V
ENERGY T$4
❑ N ❑
❑ Cenilicd Copy' is hereby Harris ed.
71to trlifiedt copy is Bled with the city inspection division.
pplicen
MISC. - REFER TO ORD.
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.uc.
CHR'('119CATF, OF EXCM1I Pf ION FROM WORK[ i RS'
PLG, CONTR. LIC, NO.
PLG.
TOTAL
COMP1iN5ATION INSURANCE
(This section need not he completed if the Permit is for one
Y ❑ N ❑
v ❑ N ❑`
OTY. MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars IS 100) or less.)
I certify that in the performance of the work lire which this per
Mit is issued, I shall not employ any person in any manner so as to
BUILDING
became subject to the Workers' Compensation Laws of California.
Date Applicant
NOTICE '1'O APPLICANT: II, alter making this Certificate of six
emptionyou sh ould become suhjrct to III, Workur,'Conlrcluatlon
rrovisinm , of the Labor Code, you must forthwilh comply with
such provisions or this permit shall be deemed revoked.
ALTER OR ADD TO MECH. 4,00
APPLIANCE 4.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10=C.F.M1 3.00
AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 2.00
• MICROFILM
1 hereby affirm that there. is a construction lending agency list
the performance of the work for which this permit is issued (See.
3097, Cie.C.). 1 d Ban
Lenders Name -d
Lender's Address
osI . 951-1-3-
I certify that I have read this application and state that the above
information is correct. I agree to comply with all City' and county
ordinances and state laws relating to building construction, and
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATI NG UN IT (OVER 100,000 B.T.U.)7.50
VENTILATION FAN (SINGLE) 3.00
ELECTRIC
PLUMBING
BOILER-COMPI3 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100,000 BTU( SEE.FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
CONST. TAX
(We) agree to save, Race ally and keep harmless the Cil, of
Cupertino against liabilities, judgments costs and expenses which
may l any way ac ue 1,ns1 said City in c ..... e,dIFca of the
PERMIT ISSUANCE 3.00
MECH. CONT. LIC. NO.
-A- ,4-n �
MECH.
TOTAL
rI I.
TOTAL
gr Y tg of 1 Is perm
4 kr-
dl
Signature of A, icant Contractor Da •
OFFICE COPY