00020019 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY Q
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMITPLUMBING-MECHANICAL a
BUILDING PROJECT IDENTIFICATION
BUILDiNGADDRES A! P SANITARY NO. APPLICATION SUBMITTAL DATE
Su A44.-I L>I -3- 2-z)
d o
OWNER'S NAME: -,r16^1h 116 PSHONL: CONTRACTOR'S NAME: ® LC NO�5 7 ,NIC CONTROL is
7-vJ 914 eN
CHI'fECT/ENGINEER: LIC NO: ADDRESS: O' / {�L-V 7_9 ,❑
CONTACT: PHONE: JJyy
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT
PLUMB MECH
❑ s ❑ ❑
LICENSED CONTRACTORS
under provisions DECLAIofTION
Chap QTY, ELECTRIC PERMIT FEE
I hereby0)at iMt I nm licensed under ndProileof Chapter 9(commencing JOB DESCRIPTION
CCz with Section 9W(pof Division 3pith.Bueinese and Professions ode,and mylicense is RESIDENTIAL:
{�OO PERMIT ISSUANCE
F W� in full force and effect. '
a'UU Lion.Class Lie
❑SFOWL ❑KITCHEN REMODEL
yZW Date Contractor APPLIANCES RESIDENTIAL ❑ADDITION ❑PLUMBING RF-PIPE
ARCHITECTS DF.CI. ATION ❑MULTI-UNIT ❑STRUCTURAL
z p-y z 1 understand my plans shall be used as public records PANELS r MODIFICATION
OZ , UPT02MAMP5 ❑INTERIOR ❑CHIMNEY REPAIR
Licensed ProfessionalINTERIOR
IMPROVEMENT
❑SWIMMING POOLS
�W ' OWNEfLBUILDER DECLARATION
Q 1 hereby affirm that I am exempt from the Contractor's License Law for the OVER IWO AMPS [I BATH REMODEL/REPAIR L1 DEMOLITION
�yWi(5 O t U following reason.(Section 7031.5,Business and Professions Code:Any city or countySIGNS ELECTRICAL a� EJOTHER
00'3 W�IQ"n^ which roqulres a permit to construct,after,improve,demolish,or repair any stmemre ,M
prior to its manice,iti.c.quirextbe applicvnr forcumiu
chpero fileasignedstatement SPECIAL CIRCUIT/MISC. 1 V
is p. that he is licensed pusuam pro
rnt the visions of the Canumeam's License Law(Chapter 9
Iy pO (commencing with Section 7")of Division 3 of the Business and Professions Code)orT P. TPR OR POLE/NST. COMMERCIAL,
xe
0,W o e' that he is empt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
tiiCl Y'
Section 9(13 LS by any applicant fora pomdt subjects the appliamto.civil peva P RDEVICE9
y not more Nan five hundred dollars($500). [:]TENANT ❑FOOD SERVICE
�ZQ ❑1,as Owner of Ne pro rt,orm 'l 'J IMPROVEMENT
pt y yvmplended es or
dfas their sole compensa MMING_POOL ELECTRIC
W ae will it,,theands: suncmfeisamual',x License Law
epplyto an owner
❑OTHER
rm and Professions Cade:The improve,
benefit License Law does not apply to an ownergh 0 LETS—SWITCHES—FIXTURES
Property who builds or improves thereon,and who does such work himself of through in
his own employees,provided that such improvements ere not amended or olPered for NEW RESIDENTIAL ELECTR SQ PI'.
pale.ILhoweventbevethe burden of
tithat he ad ntbuildat improve
the .. SQLEr, ORAREA $ISQ.FT.
ner-builder will have the burden of proving that he d7d not build nr improve for pur-
pose of sale.),
❑1,as owner of the properly,,B exclusively amuncdns with licensed cntraancrs i- �. TOTAL:
craswd the project(Sec.o an Business and rty who
ibue ds or
The es thereon,Li-crave -
whoconwdoes not orsuchplymaswitha ofproperly wcenseddsorimpro the Contractor
Y. PLUMBING PERMIT FEE
who se contracts for each projects withawntraomr(s)liammd pureoammthe Conrrucnrtx
License Law. PERMIT ISSUANCE
❑Ism exempt uvdor Sec. ,B&PC Ror this ancon
ALTER—DRAludgw W R(EA) yet TION
❑ate
WORKERBCOMPENSuryo DECLARATION p 9.
1 hereby affirm under pouchy of perjury one of the following decimations, _
F,E
❑ I haveand will mainmin n Ctiificme m Consent to self-insure fm Worker's R, 1 A,COND, STORIES TYPB CONSTRUCTION
colica,us provided for by Section 37W of the Labor Code,fort eH a
work for which this permit is issued. _ FIXTURE — gR21sRAP'$.^^
❑ 1 hove and will maimain Workcis Compensation I ranee;as e air
000'00
x '
39of the Leber Code,for the performance Of No woo NwhLETS
�Clf Irc it is issued. ;;i YSTEW N OCC GROUP
My Worker's Compensation Insurance carrier and Policy i lX// C h EASYSTEM- _ p �
Carrier. Policy No.: DVERV
CERTIFICATE OF EXEMPTION FROM WOR S' s J 647
COMPENSATION INSURANCE GRF IA BNUUSTRLWl!kV INT R
(Thissemionneed vat be completed lfthe permit is frame h i 0$10) +T1 NUII.UINO DIVISION FEES
or leas) REys�O ,v r W PLANCHECK FEE
I certify that in the performance ofthe work for which this a iti �P _SANITARY—STORM EA.2W IW. ENERGY FEE
not employ any person in any manner so a to become sub, w r
.anion Laws of California.Data
ZO Applicant I WATER HEATER W/VENTEELECTR GRADING FEE
(r y NOTICE TO APPLICANT:If,after making this Cenifeme 01ripti0n,you should WATER SYSTEMGREATING
ai become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
W forthwith comply wilhauch provisions or this permit shall be deemed revoked. WATER SERVICE -
Q
U O CONSTRUCTION LENDING ngagerAGENCY NEW RESIDF,NTIAI.PLMB. SQ.FT. PAID
I hor which his
(Sac.3097,
agency for the performance of Dvrc ReceiptN
(L
Leader's Name
for which this permit is issued(See.309],Civ.CJ
Q Lender's Name TOTAL:
} LUL/ Lender's AddressTOTAL:
I certifyythat I have read this application and state that the above information is BUILDING FEE
r�r Va) correct.I agree tp comply with all city and count,ordinances and since laws relating to QTY. MECHANICAL PERMIT FEE
U building construction,and hereby urdhodm representatives ofthis city to worm Pon the SEISMIC FEE
abnve-me diened property for inspection purposes.
(We)agree to save,indemnify and keep handles,the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgmems,co sand expenses which may in any way acme against said City ALTERORADDTOMECH. PLUMBING FEE
in cm,calte egr ting Mthispermit.
APPLIC nc ON . STAND AND WILL COMPLY ITH ALL NON-POINI AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FEE
S U E
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Srgnalure of Applearb Convector Date^ EXHAUST HOOD(W/DULY) HOUSING MITIGATION FEE
HAZAR SMAT[ ALS DISCLOSURE
Willtbcapthen for future bulldin occupanlsmrecr handle ha¢adous mmoal HEATING UNIT(TO 100.00)BTU)
ax defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532nd? HEATING UNIT(OVER 100,1gM1 BTU)
E]Yes E]No PAID
VENTILATION PAN(SINGLE RESID) Date Receipt it
Will medaus applicanlor innts aure definedding by the nt Byse Aea Air Qualitment or y
Management
BOILER—COME HGO00 BTU)
emit huvrdous air contaminants as defined by the Bay Area Air Quvlity Munagemen[ TOTAL.
District'
❑Yes ❑No BOILER—COME(OVER IW.OW BTU)
I have reW�.OA
requirements under Chapter 6.95 of the Call- AIR CONDITIONER ISSUANCE DATE
fomis Heal 5,2 .1 and 255]4.I understand dint if the NEW RESIDENTIAL MECH. SQ.Ff.
buil in it y�Aspnnsihility to notify the occupant'sconce ofaCertifi roofOccv cyct orData TOTAL: ISSUED BY:
OFFICE
)ICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
• BUILDING PERMIT INVOICE OPERATOR) karenb
Sec: TVP: Rng: Sub: Elk: Lot:36932009.00
INVOICE DATE......: 02/02/2000
REFERENCE ID # ...: 00020019
SITE ADDRESS .....: 10225 S BLANEY AV
SUBDIVISION .......
CITY CUPERTINO
IMPACT AREA .......
OWNER PORTH WILLIAM H AND MARY E
ADDRESS ..........:
CITY/STATE/ZIP ...: CUPERTINO CA, 95014-3184
CONTRACTOR .......: GUHIN, TIM LIC # 21457
COMPANY ........... MISSION CONSTRUCTION
ADDRESS 613 BAY VIEW DR
CITY/STATE/ZIP ...: APTOS, CA 95003
TELEPHONE ........i (831)688-1573
DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
----------- _-- ____________ -----------
WP MP P 57.50 0.00 57.50
9LIC P 90.00 0.00 90.00
ERMITFEE P 35.52 0.00 35.52
____________ ___________
183.02 0.00 183.02
ICE I6 DESCRIPTION VOICE ID DESCRIPTION
...... ............................ ........ ............................
103 UPER 304 ROUGH ELECTRICAL
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