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99100024N/ APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY of C7 / OOU-2q Ad Mee XLicensed pZ" Qthen 00 zzy, CITY OF CUPERTINO I - BUILDING - ELECTRICAL - PERMIT NO. BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL BUILDING PROJECT IDENTIFICATION JVl/t9'� BUILDINGADDRESS: - aagK c.T SANITARY NO. AP�CATIONUBM�L DATE OWNER' N E: ��NE: CONT CRG 7pR'S NAMf3: LIC NO_ NIC ❑ CONTROL# ARCHITECT/ENGINEER: LIC NO: - ADDRESS: INTACT: PHONE: :BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant (Initial) BLDG ELECT PLUMB MEC LICENSED CONTRACTORS DECLARATION 1 hereby v[flrm th t 1 r o d we p ',' f Chapter 9 (comm ssi.ns Code, and my lice in full fore.iodeDee. `7 3, License Cose/�� Lie# {ucan,,. tar ELHCTRICP,E' MIT ', ( FEE { Z JOB DESCRIPTION RESIDENTIAL:� ❑SFOWL ITCHEN BE ODEL ❑ADDITION ❑PLUMBING RLPIPH ❑MULTI -UNIT ❑STRUCTURAL MODIFICATION ❑INTERIOR ❑CHIMNEY REPAIR ERMITISSUANCE PPL]ANCES-RESIDENTIAL ARCHITECT'S DECLARATION 1 understand my plans shall be used as public rccOrds -PT02110gMP5 Jg9 ANELSyZ' Professional OWNER -BUILDER DECLARATIONVEk I hereby vfrom then J am exempt from the Conlmetor's License Law fdU following reason 15edion ]03 L5, Business and Professions Code: Any city a which requires a permit to construct, alter, improve, demelish, or repair nay mature prior,. its isaumnce, oleo rNeinstho appliemaTo, such permit to filemsigned statement Inc is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing as ith Section 7") of Division 3 of the Business and Professions Code)or that he Ie exempt therefrom and the basis for the alleged ouoma mn Any violation of Section 90315 by any applicant for apeot,odres the applicant m o civil penalty of not morethan fivehirectedpreptedollarsyempl. ❑ Las owner of the property, ormy employees with wages as ,halt sole compensation. will do the work, and the saucmm is no, Intended interfered forsmle(Set. 9044, Business and Professions Code: The Contractors License Law does not apply to an owner of 01-IMOAMPS r� ey, W m d G m IMPROVEMENT' . OSWIMMING POOLS ❑ ft H REMO REPAIR D 101.ITION fH R IOW AMPS IGNS ELECTRICAL _ S' SPECIAL CIRCUIT/MISC. TEMP. METER OR POLE MST MITIMERCIAL, C7 0 ❑ NEW BLDG/ADDIT'ION ❑DEMOLITION ❑TENANT ❑ FOOD SERVICE. IMPROVEMENT - OTHER POWER DEVICES t r SWIMMING POOL ELECTRIC OUTLETS -SWITCHES -FIXTURES property who look s er improves There.n, and who tines such work himself or through his own employees, provided that such improvements are not intended or offend for NEW RESIDENTIAL ELECTR - SQ FT. sale. If, however, the buildingor improvement is sold within one yemof complenoo, the - }� SQ. FT. PIAOR AREA 5/SQ. Pf. ser -builder will have the burden of proving that he did not build or improve for par- V - pose.LsnleJ. - TOTAL ❑ 1, as owner of the property, am exclusively contracting with licensed cOtnamors m onetrocuhe project (See. 9044, Business and Professions CodoU The Contractor's Li- ae Law does not apply to nn ownerofpmperfy wboboilds orimprovec Thereon, and - y. QTY, - PLUMHiNO PERMIT', j FEE-�` wan wnnmOls fm aich projects with a contmetoo d licensed pursuant to the Contmmor's PERMIT ISSUANCE ' License Low. E:1I am exempt under Sec. B.@ P C for this reason ALTER- DRAIN a VENT - WATER (EA) Owner Date VALUA'HON WORKER'S COMPENSATION DECLARA PION BACK FLOW PROTECT DEVICE - I hereby affirm under penalty of perjury one of the following decimations: I= DRAINS- FLOOR, ROOF, AREA, COND. ❑ I have and will maintains Cenificam of Consent to self -insure for Worker's C.mpen- tionSection, as provided far by Section J]OO oldie Dust, Cede, for the performance of rho STORIES . 'TYPE CONSTRUCTION FIXTURES - PER TRAP r for which this permit is issued. 1 have and will maintain Workers Compensation Insurance, as required by Section J O of the Labor Code.forthe performance of The work for which this patron., Issued My Worker' tape anon lam p ri ad Policy arbor ( Carrie:tiM�.(y i�os.Pnlicy No.: arbor - GAS -EA. SYSTEM -1 INC. 4 OUTLETS OCC. GROUP C^/ATN O J V GAS- EA. SYSTP.M-OVER4(EA) CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Thisaedom needco no, Pit, Nor, is for one hundred dollars is 100) or less) GREASE/INDUSTRL WASTE. INTERCEPTOR t n . X A' '?sa tBURTENQ QUIT O FRES _ti - GREASE TRAP PLANCHECK FEE SEWER -SANITARY- STORM EA. 200 PP.' ZLawsAppin � Toy dfyan, pm.. to perany inmoser.. asing this Perthe Wilsissue3rrion- TMEall becameoakfur not employ coy person in any manner so as to hecome nubjed m the Workers' Qompen- of Califom. Date iu Appllcam t - ENERGY FEE WATER HEATER WNENVELECTR GRADING PEE NOTICE TO APPLICANT: If, after making this CenlMomof Esem tion, you shoulJ P become subjecttothe Worh pri i,amsr This provisions of the Labor Code, you muco forthwith comply with such pmvisinns nr This permit shall be deemed revoked. - WATER SYSTEM/fkEAf1NG - Q SOILS FEE WATER SERVICE 1 NEW RESIDENTIAL PLM. SQ. FT Z p Hthe U {1a y CONSTRUCTION LENDINGAGENCY reby which rte thattherei honed TSev.30on l,agency for the performance of I for work for which this permit is issue( (Sea )099, Co.Cie CJ Lenders Nam. PAID ' Dae wipt# ' '*TOTAL' Lenders Address TOTAL: I certify than have read this application and state that the above information is _ BUILDING PEE - .. - h Z correct l agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to cater upon the •QTY, MECHANICAL PERMIT. FEE - SEISMIC FE shove -mentioned property for inspection purposes. I (We) static to save, indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC PEE liabilineajmdgmeres, costs andespemes which may many way secrucagaine,i id City in asequence of the granting of this permit. ALTER OR ADD TO MECH. PLUMBING PEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT SOURCE REGULATIONS. AIR HANDLING UNIT (TO 10,1100 CFM) MECHANIC EF. AIR HANDLING UNIT (OVER 10,000 CFM) CONSTRUCTIO AX EXHAUST HOOD(W/DUCT Signature of ApplicanNConfinemr Dat— MATERIALS DISCLOSURE HOUSING MITIGATION FEE - If EATING UNIT TO 10(1.00(1 RED) Will the applicant or fulurebuili ing oc,,,,nI,tom er handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Code, Section 25532(a)' HEATING UNIT (OVER 100,000 BTU) ❑Yes.:I Nu C� Will the spplleant or ormartnm refund Air Qualitnt or y Arcccupant use o by emit hazardous air cnnmminents as defined by the RayArea Air Qvaliiy Management Managees ant District yes.RI No PAID Dom Receipt# VENTILATION PAN (SINGLE RESID) BOILER- COMP (THP OR 100,000 BTU) _ TOTAL: 03 BOILER- COME (OVER 100,000 BTU) AIR CONDITIONER Ihuve re ad the hmanlous materials rcquircmenu under Chapterh95 of the Culi- -- ISSUANCE DATE NEW RESIDENTIAL MECH. SQ.IrI'. Tom's Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that If the makld,ngdcesnotwnently heveamnont. that it is my respoosiblllty to notify the.mupam /v- (,.,, mthe reyaire ms which must be met prior t. issuance ora Certifiwt f / F' TOTAL: Owner ar authodzed agent TDA ISSUED BY OFFICE CITY OF CUPERTINO Item 1 of 1 BUILDING PERMIT RECEIPT OPERATOR: christya • COPY p : 1 Sec: Twp: Rng: Sub: Blk: Lot:35603011.00 DATE ISSUED.......: 10/06/1999 RECEIPT p.........: 10254 REFERENCE ID N ...: 99100024 TOTAL RECEIPT A. • 751.03 SITE ADDRESS .....: 22405 BALUSTROL Cr SUBDIVISION ....... - CITY .............: CUPERTINO IMPACT AREA ....... OWNER ............: KEELER FRANCIS W JR AND MARGAR ADDRESS ..........: CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-3948 RECEIVED FROM ....: TIM CONTRACTOR .......: ROHRER, ROSS LIC # 20605 COMPANY ..........: CLEAR OAK DESIGNS ADDRESS ..........: 1723 ROGERS AVE CITY/STATE/ZIP ...: SAN JOSE, CA 95112 TELEPHONE ........: (408)436-5448 FEE ID __________ UNIT QUANTITY AMOUNT _____________ PD -TO -DT THIS REC NEW BAL BENERGY ________ PERMIT FEE 257.00 ---------- 77.10 0.00 ---------- 77.10 -----_____ 0.00 BPERMFEE VALUATION 20,000.00 257.00 0.00 257.00 0.00 BPFIKTURE UNITS 2.00 16.66 0.00 16.66 0.00 BPGAS OULETS 1.00 4.44 0.00 4.44 0.00 BF200 METERS 1.00 22.20 0.00 22.20 0.00 HK PERMIT FEE 257.00 218.45 0.00 218.45 0.00 P TFEE FLAT RATE 1.00 35.52 0.00 35.52 0.00 BREMRECEPT NO. OUTLETS 18.00 19.98 0.00 19.98 0.00 BREMRESAPP NO. APPLIANCE 6.00 26.64 0.00 26.64 0.00 BSEISMICRE VALUATION 20,000.00 2.00 0.00 2.00 0.00 EPERMITFEE FLAT RATE 1.00 35.52 0.00 35.52 0.00 MPERMITFEE FLAT RATE 1.00 35.52 0.00 35.52 0.00 TOTAL PERMIT ---------- ---------- 751.03 0.00 ---------- 751.03 ---------- 0.00 METHOD OF PAYMENT AMOUNT _____ NUMBER CHECK ------------ 751.03 ------------------ 29427 TOTAL RECEIPT A. • 751.03 CITY OF CUPERTINO Item 1 of 2 BUILDING PERMIT RECEIPT Sec: Twp: R 9: Sub: Elk: Lot:35603011.00 • DATE ISSUED.......: 10/06/1999 RECEIPT 4.........: 10254 REFERENCE ID # ...: 99100024 SITE ADDRESS .....: 22405 SALUSTROL CT SUBDIVISION ....... CITY .............: CUPERTINO IMPACT AREA ....... OPERATOR: chrietya COPY # : 1 OWNER ............: KEELER FRANCIS W JR AND MARGAR ADDRESS ..........: CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-3948 RECEIVED FROM ....: TIM CONTRACTOR .......: ROHRER, ROSS LIC # 20805 COMPANY ..........: CLEAR OAK DESIGNS ADDRESS ..........: 1723 ROGERS AVE CITY/STATE/ZIP ...: SAN JOSE, CA 95112 TELEPHONE ........: (408)436-5448 FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW SAL VOICE ID DESCRIPTION VOICE ID DESCRIPTION ........ 101 ............................ FOUNDATION ........ 102 ............................ PIERS 103 LIFER 104 REHAB 105 ANCHOR BOLTS 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 203 UNDERFLOOR MECHANICAL 204 UNDERFLOOR FRAME 205 UNDERFLOOR INSULATION ROUGH PLUMBING 302 TUE & OR SHOWER 46 ROUGH MECHANICAL 304 ROUGH ELECTRICAL FRAME 306 HOLDOWNS 307 INSULATION 308 SHEETROCK 309 EXTERIOR LATH 310 INTERIOR LATH 311 SCRATCH COAT 313 ROOF NAIL 501 FINAL ELECTRICAL ENERGY 502 FINAL PLUMBING ENERGY 503 FINAL MECHANICAL ENERGY 504 FINAL BUILDING ENERGY 505 FINAL ELECTRICAL 506 GAS TEST 507 FINAL PLUMBING 508 FINAL MECHANICAL 509 FINAL GRADE 510 FINAL PLANNING 514 FINAL PUBLIC WORKS INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE CITY OF CUPERTINO BUILDING PERMIT INVOICE OPERATOR: christya Sec: Twp: Rng: Sub: Blk: Lot:35603011.00 INVOICE DATE......: 10/06/1999 REFERENCE ID # ...: 99100024 SITE ADDRESS .....: 22405 BALUSTROL CT SUBDIVISION ....... CITY .............: CUPERTINO IMPACT AREA ....... OWNER ............: KEELER FRANCIS W JR AND MARGAR ADDRESS ..........: CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-3948 0 CONTRACTOR .......: ROHRER, ROSS LIC W 20605 COMPANY ..........: CLEAR OAK DESIGNS ADDRESS ..........: 1723 ROGERS AVE CITY/STATE/ZIP ...: SAN JOSE, CA 95112 TELEPHONE ........: 1408)436-5448 FEE DESCRIPTION CHK TOTAL FEE PAID -TO -DATE BALANCE DUE _______________ BELEC200 ___--------- P 22.20 ------------ 0.00 ____--_____ 22.20 BENERGY A 77.10 0.00 77.10 BPERMFEE P 257.00 0.00 257.00 BPPIXTURE P 16.66 0.00 16.66 BPGAS P 4.44 0.00 4.44 BPLANCHK A 218.45 0.00 218.45 BREMRECEPT P 19.98 0.00 19.98 SAPP P 26.64 0.00 26.64 ICRE P 2.00 0.00 2.00 E TFEE P 35.52 0.00 35.52 MPERMITFEE P 35.52 0.00 35.52 PPERMITFEE P 35.52 0.00 35.52 --------- 751.03 ------------ 0.00 ----------- 751.03 0 CITY OF CUPERTINO BUILDING PERMIT INVOICE OPERATOR: christya CONTRACTOR .......: ROHRER, ROSS LIC # 20805 COMPANY ..........: CLEAR OAK DESIGNS ADDRESS ..........: 1723 ROGERS AVE CITY/STATE/ZIP ...: SAN JOSE, CA 95112 TELEPHONE ........: (408)436-5448 VOICE ID Sec: Twp: Rug: Sub: Blk: Lot:35603011.00 DESCRIPTION INVOICE DATE......: 10/06/1999 • REFERENCE ID # ...: 99100024 UFER SITE ADDRESS .....: 22405 BALUSTROL CT 105 SUBDIVISION ....... " SEWER & WATER CITY .............: CUPERTINO 203 IMPACT AREA ....... 204 UNDERFLOOR FRAME OWNER ............: KEELER FRANCIS W JR AND MARGAR 301 ADDRESS ..........: 302 TUB & OR SHOWER CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-3948 CONTRACTOR .......: ROHRER, ROSS LIC # 20805 COMPANY ..........: CLEAR OAK DESIGNS ADDRESS ..........: 1723 ROGERS AVE CITY/STATE/ZIP ...: SAN JOSE, CA 95112 TELEPHONE ........: (408)436-5448 VOICE ID DESCRIPTION VOICE ID DESCRIPTION ........ 101 .................... ....... FOUNDATION ........ 102 ............................ PIERS ,103 UFER 104 REBAR 105 ANCHOR BOLTS 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 203 UNDERFLOOR MECHANICAL ' 204 UNDERFLOOR FRAME 205 UNDERFLOOR INSULATION 301 ROUGH PLUMBING 302 TUB & OR SHOWER 303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL 305 FRAME 306 HOLDOWNS 307 INSULATION 308 SHEETROCK 309 EXTERIOR LATH 310 INTERIOR LATH 311 SCRATCH COAT 313 ROOF NAIL FINAL ELECTRICAL ENERGY 502 FINAL PLUMBING ENERGY ps FINAL MECHANICAL ENERGY 504 FINAL BUILDING ENERGY 5 FINAL ELECTRICAL 506 GAS TEST 507 FINAL PLUMBING 508 FINAL MECHANICAL 509 FINAL GRADE 510 FINAL PLANNING 514 FINAL PUBLIC WORKS 0