2565 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
SDo S APPLICATION & PERMIT 2565
NORTH PORTAL BUILDING — ELECTRICAL—PLUMBING—MECHANICAL
ER'$� ,yy•^ I PLAN CHECK VALIDATI ON
NAME (,(' aI/i(R;(,TAY-121 Q� �� �)(�r�/ OTy. ELECTRIC PERMIT �F_EEi
PHONE 4-IIY I PAID
croRs
NAME OUTLETS-SWITCHES-RECEP 5.00/1,00
NAME
ROUNTREE PLUMBINGLIC.No, 365489 LIGHTING FIXTURES 5.00/1.00
CONTRJAN ,3 11984
BUADDREACTOR'S 1367 MARSTEN RD PPLIANCES-RESIDENTIAL 4.00
ADDRESS
RLINGAME CA PHONE 348-556E PANELS 5.00 PWPGN
ARCHITE`T DENNIS KOBZA S ASSOC SIGNS 6.00 PL C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENGSPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 15.00
APPLICANT'S
ADDRESS 1367 BURMA
LINGAME CATE94010 SN RD ESTORS EE FEE
SERVICE CHANGE 1000
w
02 LICENSED CONTRACTORS DECLARATION I
a u U I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
H Q a, (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PL MECH.
r H z Professions Cod a y license is in lull for f�� ❑ ❑ ❑
Z, o w License .la Lic.Number
z Date Coutracmr
a Y F 11IIff..,,11 Ttx�f- � HTG " !",BUILDING RMIT-., :
rt ¢w OWNER-B UILBL 'BEf�ARk`IYON _ INFORMATION -
s o a MISC.— REFER TO ORD
X ;LL N 1 hereby affirm that I am exempt from the Contractor's License VALUATION
� Lo ¢ Law for the following reason. 7031,5,Businessand Professions pERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,alter.
¢ improve,demolish,Or repair any structure,prior m its issuance,also ELEC.CONTE. LIC,NO. ELEC.
E o u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
A w mhe is licensed pursuant to the provisions of the Contractor's License
H z i Law(Chapter 9(commencing with Section 7000)of Division 3 oftheI
a Business and Professions Code)or that he is exempt therefrom and OTY."`_ .PLUMBING PERMIT x ''FEE` L
f i o
¢ H $ the basis for the alleged exemption.Any violation of Section malty - - ST RIES T E CONSTR.
by any applicant for a permit subject the applicant to a civil penalty
of not more than five hundred dollars(5500).)'. ALTER-DRAIN& VENT-WATER (EA.) 4.00
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 2.00 DCC.GROUP RES.UNITS
their sole compensation,will do the work,and the'truc l ure R no
• intended or offered for sale ISec. 7044. Business and ProfessionsAr
DRAINS-FLOOR 07 AR EA,COND. 4.00
Code:The Contractor's License Law does not apply m an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered 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- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING SE
builder will have the burden of proving that he did not build or m. RES IN
O O PB Omer
prove for purpose of sale.L 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 ASSESSOR 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 forsuch projects with a contractorls)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ l am exempt under Sec.—. for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACL.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
capyth{{��rfF� ".C). NORTHWESTERN
Policy IJP1. any
Q ❑ CeNlfleddd.x.pyij1hiOvby famished. FIRESPRINK ENERGY T-24
Z O Apq.c,n` p s fl d wit] 1 y inspection division. MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ No
CCN 6}1 CERTIFICATE OF �(EMPTION FROM WORKERS' PERMIT ISSUANCE 6,00 O
FLOOD ZONE A.LU,L.
LU 7 COMPENSATION INSURANCE PLG.CONTR. LIC.NO, PLG. V❑ N❑ Y ❑ N❑
CL D (This Section need not he completed if the pefmit is for one TOTAL ,6�
=) Z hundred dollars IS 100)or less.)
U 0 1 certify that in the performance of the work for which this per OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
Ow become subject to the Workers'Compensation Laws of California. BUILDING
y Date Applicant ALTER OR ADD TO MECH. 4.00
>_ to NOTICE TO APPLICANT: If,after making this Certificate of Ex
♦— 2 emption.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 14000C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.15.00 SEISMIC FEE
I hereby affirm that there 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,CN.C.). HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UN IT(OVER 100,000 B.T.U.)7.50
Lenders Address ELECTRIC
I certify that I 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 county BOILER-COMPO H.P.or 100,0008.7.U.) 4.00 PLUMBING %' D
ordinances and state laws relating to budding construction. and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100.000 BTU)SEE FEE SGH, MECHANICAL
above-mentioned property for inspection purposes.
(We) agree t0 save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and vipenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in true against said City in c quence of the
t MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL'"
ftn'difiiie of Apphcmtt/C actor Date
OFFICE COPY