S 0001 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING.ELECTRICAL P'
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MCCHANICAI, 0001
-
BUILDING PRoincir unwrIF CATION "
BUILDING ADDRI?SS: SANITARY NO. // //y. TE
OWNE NAME: PHONE VO CONI'RAC'IYIR'S NAMIi: LIC NO r 15
l NIC CONTROL#
. &161912sx1t:4.
RC HITECTIENGINEER: LIC NO. ADDRHSS. // ,, dfY� ❑
14 K
S a! So e l5/A71COW
CONTACT: PHONE'. BUILDING PERMIT INFO
c,wLgeS F-L K.y e2P� -.)3'9F
�a� SO' I�c-SLo.k /Yxq ❑ Consultant Pres Paid By Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARAB']ON Q'TY ELECTRIC PERMIT - FEE
I hereby affirm that I.m licensed under provisions if chapter 9(commencing _ JOB DESCRIPTION
FMaZ with Seems, Division Sof the Business and Prom.mnscode.and my license is RESIDENTIAL:
O in full tome nn0 eRec PERMIT ISSUANCE
WWF ALO ❑SFDWL ❑KITCHEN REMODEI,
Q,UU Lmease Clao Lm. gpPLIANCI?S-RPSIUF.NTIAL -]ADDITION El PLUMBING RE-PIPE
F-Q W Date Contmcmr
ARCHITECTS DECLAOMDON ❑MULTI-UNIT []STRUCTURAL
Z O In z 1 marm and my plan shall be use)as public records PANELS S
MODIFICATION
OZ4p UP T0210 AMPS ❑INTERIOR W1 CHIMNEY REPAIR
Licensed Professional 201-100AMPS IMPROVEMENT C]SWIMMING POOLS
m OWNER BUILDER DECLARATION OVER I NOAMPS C1 BATH REM1fOU REPAIR ❑UGMO.ITION
6 I hereby affirm that 1 am exempt from the Contractor's License Law for the
O a U following reason.(Section 0031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
dfo
which s Permit to consuuct,ager.int ersa demolish,or m armature —
to issuance,also res the applicant for such permit file ax signed statement /s�1)e.lr C81 it
Prirr regal PP I B SI'IiC1A1.CIRCUIT/MISC.
a, y that he is licensed pue,aenfto the provisions of the Comranols License Law(Chance
I�+I�CO� (commencing with Section7001 of Division 3 of the Business and Professions Code)or TEMR MITER OR POLI? ST. COMMERCIAL'
6 6 e C that he is exempt therefrom and the basis for the allege)corruption.Any GOIRLIon of ❑NEW BLDG/ADDITION ❑DEMOLITION
K m a Section 7031.5 by any applicant for a femai subjects the applicant to a civil penalty of POWER DEVICES
W^to ❑TENANT ❑FOOD SFRVICH
=Q nt more than five hundred dollars 13510).
❑ Las owner of the pmpeny.ernry employees with x'agesa their role nompensatinn, SWIMMINGPOG. ECTRIC IMPROVEMENT
F- will Jo the work,and the Norman,is not intend or
intended for sale lSec.7(W,Husinesx ❑OTHER
MRm and Professions Code:The Cmansam's License Law does not apply m uit owner of OUTLETS-SWI HF_S-FIXTU S
3 propany who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements am n o intended ar.ff- -• for NEW RESNLNTIAI.1?LECIR SQ FT.
.Is.IT,Kram ar,thebulldingorimprovement issmil withinone ycaofcontpletinn,the SQ.FT.FLOOR AREA S/SQ.FT.
ter builder will have the burden of proving that he did not build of improve for put.
N¢of sole.).
1,as owner of the propeny,am exclusively contracting with license(]commerce,to TOTAL:
conswct the pmjeut(Sec.7044,Business and Pmfcssions Cc-..,The Ccnwctar'I.-
omlawdoesnotapplyn,an owner ofpropeny who bolds or improves memar,and QTY, PLUMBING PERMIT FEE,
who contracts for such projects with a commemns)licensed pue,vam to the Contmrmrs
License Law. PI?RMI'(ISSUANCE
1 am exempt under Sec. ,B&P C far this reason
Owner Data AVER-DRAIN&VENT'-WATER EA) VALUATION
WORKERS COMPENSA'1'LON DECLARATION RACK PLOW 1' ECT.DEVICE // A N-g p. OD
I hereby ifdnn under penalty of perjury one of the following declarations:Ilk aa0.CC L !J
I M1ave and will mainminu Cenificme nfGmmnt In sdGinsurc for Wnrkcr'n Content- DRAINS-FLOOR, OF,AREA,COND. STORIES TYPE.CONST RUCTION
sation,as provided for by Section 3700 of the La s r Codc,far the perfannancc of the
work for which this pamtit is acted.ed. FIXTU It IS-PER TRA]'
371haveandwillmainwin Worker's Cote of
he wrkforee, hhisper by Section
3)1X1 of the Labor Code,for the perfoomnce of the work for which this permit is issued MS-IiA.SYS'I'1iM-I INC. OU' ,ITS
My
,la,!tonresettle,and PolicyOCC.GROUP
PIS
Policy
Policy No.: ta2y-gkGAS-PA.SYSTEM-OVER ? 3
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATIONINSURANCB Ep I/1/poor 0111?ASI%INUUS'fRl. STEL '1'IiItCEPTOR
(Thi,,arnan need not bcmnnplmed]f the immul is far one bumhra dol luau 1S 100) � • . BUILDING DIVISfONIT?P.S
oe Icse) CIt17ASl!'1'RAP PLANCHECK PEE
I„nlfy that in the wanounme nfthe work far haft du,Trnniti.siesncd.l Ahall SEWER-SANI'ARY-STORM .211111T.
nal employ any Fromm in nnymanncr sons to become ml,fro ,the Worker:Compcm ENERGY FEP,
Z scion Lows r1 California Dot, WA'I ER HHArER W/VFN'1'IHLECI'It µ
z Q Applicant t �ORAdING PBE l
z y NOTICE TO APPLICANT R;nficr nmking this Canldnnc of Exrrnplion,you shmdd WATI?R SYS'fl?M/flit?A'fINO
abecome eobject ,,the Wmkers Cnmlwnsatlon provisions of the Labor Cade,you nnul r� Stan's EE'.
GLI frnhwith comply with such provisions or this pernli shall be dremed revoked. WAIUR SERVICE Ill
199
� z CONSTRUCTION LENDING AGENCY NIiW RESIDENT[M,PLMI3. SQ.Ff. #-
I
P,S1[ �1_�
U Q I hereby affirm that is a construction lending agency for the perllmaance of E Date Remip
L>r the work for which this permit is issued(Sec 3097,Cie C.)
0 U Lender's Name 'TOTA
} a Lender's Address TOTAL: -_
certify that I have rend this application and stare that the above in]itmwnom is - - 13 UIIOING FF.
h conem.l agmumcomply withml city and cnumynNinanc,>und arum rows relatingm QTy. MECHANICAL PERMIT FEE
L.) Z findidngcrnsaamirn,andherehy mehurite upormoortivesofthis city tacntrruprnthc SEISMIC FF.F,
above-mentioned property for inspection purposes. PI?RMI"1'ISSUANCE
(We)agree to rove.Indemnify and keep harmless the City of CtFi against ELECTRIC PEE
liabilities,judgments,costs and expenses which may in anywaynccme ugainstsaid City ALTER ORADDTO MECH.
in consequence of the gaming of this peo.k. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING O (TO 10,II0(i
SOURCE REGULATIONS. MSCI IANICAL FEE
AIR HANDLING UNIT OVER 10 ICFM) CONSTRUCTION TAX
Signature of A,barnVCommctor Dam EXHAUST HOOD(WAR HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building warrant store or handle havardnua ntmerial HEATING UNIT(To HA BTU)
as defined by the Cupertino Municipal Code.Chapter 9,12,and the Health andSafay
Craft.Section 25532(s)? HEATING UNIT G . H 1N
WN1 HTU)
LJ Yes is. VENTILAHONT N(SINGL.RESID) PAID --
YY. Date Receipt If
Will the air contacamminants
infumrc buidefinedding wauteythemuseequipmentordevicewhich BOILER-COMP SHP OR 100,000 BTU)
emit District'
us air cumaminnnts as defined by the Bay Arca Air Quality Management TOTAL:
Distnn?
C]Y" 11g No IIOILBR-COMP(OVER 110.(NN)R'N)
I have read the hicamima materials requirements under Chapter 6.95 of the Cali AIR CONDITIONER
9 P ISSUANCE DATE
from.Health&Safety Cads,Sections 21505.8533 and 25534.I understand that if the NEW RfSIDM- [At,MECH. SQ.E n O
building does not currently have a tenant,thio it is my mprnsibilay to notify the occupant / ) �% a@f Q
of the require is which nest met prior to issuance ofa Cenificat rf(keup:mcy. L
Owner lir authotn age ' Dam TOTAL: ISSUED BY:
OFFICE
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE `
CITY OF CUPERTINO
BUILDING PERMIT INVOICE OPERATOR: nancyc
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Sec: Twp: Rug: Sub: Blk: LOC:32659017.00
INVOICE DATE..... . ; 12/10/1999
REFERENCE ID # ... : 99120075
SITE ADDRESS .....: 10299 ANN ARBOR CT
SUBDIVISION . . .....
CITY . . . . . .. ......: CUPERTINO
IMPACT AREA ...... .
OWNER ............: BUNZEL DAVID L AND HAE W TRUST
ADDRESS ..........:
CITY/STATE/ZIP ... : CUPERTINO CA, CA 95019-1650
CONTRACTOR . . . .. . . : LIC #
COMPANY . . . . . . . . . . :
ADDRESS .. .. . . . . . . :
CITY/STATE/ZIP ... .
TELEPHONE ........ :
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- --- --------- ------------ -----------
BPERMFER P 77.00 0.00 77.00
BSEISMICRE P 0.50 0.00 0.50
--------- ------------ -----------
77.50 0.00 77.50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
.. ........ ............................
FOUNDATION 312 CHIMNEY REBAR k STRAPS
4 FINAL PUBLIC WORKS
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