00030086 CITY OF CUPERTINO PewMrr No.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDINGADDRESS: - I� /err I D 3(J`••]
TOKH F��a^I 1�(A{.�N+VJt�'IU YJ � r� SANITARYNO. APPLICATION SUBMITTAL DATE
OWNS . A �/ I�J��rh N/C CONTROLM
PHO 3 Jbi1 ,//7s • r , •❑
ARCHITECT/ENGINE
� — "A BI1LOlNq PBRMITINFO
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Z O H LICENSED CONTRACTORS o LA O -
O 1 hereby 0)thio I am licensed....i rnvisions of Chapter 9(cotmmminis Job Description
�; wine Smtion]Otp)of Divicion3o(da Business std Profession,Code.and my licen is fps n
a O E in full force and cR Lic:ti �'ee 61,0-", (AJ 1� / ,,3 9'e4P", /J, WO
mos la
>pi e,p F Dete Convaclar
�k�C� ARCHITECTS DECLARATION I
p�j. .�Q11i�lgdaf9�plena h:aedu public records
0
uadrsW PyglgfatW ( s y s�P st-3 ,
OWNER- RDE CLARATION / r"
16ertby ethm Inn exempt I em exempt from the Conon,Coulw An,s Law for the
G following naso..(Bodian 7031.5,Betimes and vc,&Profession,Cade:Any city m munry
mM which its issuance,
i s a a permit m ceras the alter,impasse,dnermit t m mash any tared urn - S Ft. Floor Area Valuation
thelhe fits issunnm,sun ment in the trivili icaof tet smhpemdtroices.le a gaedamtemem - tl•
Nminumcm widpursuam in the pro visions 3da eDeal to and Profession.
(CTapref9 5
that he is ingwiNSenfromirst su0l theof Division for ofmeBminexeandon.Animalation r Occup% cy Type
Nn io is exempt any appli and Ne basis far be elkged exemption.Any violation of APN Numberrs�Y
-red
Section man by anyapplicantdeur for a 00). bjmtr da applicant to a civil Pendry of / 3'O U f Ae r.
not more Nen five hundred dollars(3300). -� LJ y
Dl,as owns of me properly,mmy employms with wagesu Meir sole compemanov, Required Inspections
will dome work andtheavuclu a is net inandedmoReted ferrule(So.7044,Business
and Pmfauam'Code:The Contranm's Limner law 4.am apply a.we owner of
property who builds or improves thereon,and who does each work himself or through -
- 4 his We employees.Provided that such imp rveremts arc not intended or oRcmd for - -
sale.If,arnimss,the building or improvement is sold within one year of mmpletir,,the
mer-builder will have me burden a proving that he did not Wild or improve for for-
,,ex,.)
1,as owner of the property,am exclusively contracting with licenced'contractors of
consouct the project(Sm.7W4,Business and Prokaaiona Cade:)The Contracmrs U. -
cense LOW dens not apply to an owner of property who build%or improves Hereon,end
who contracts for each Pmjects with a contractor(s)licensed pureaant to the Contractors (';
License Law. ' r
❑tem exempt under Sec. ',B&PC for Wsrauon 1 '
Owner Deer ` J_
WORKER'S COMPENSATION DECLARATION `Ver✓
Ihanwaffirm under pemllyof lteisf0inety raof if-insse owior chic,nWorkers Co
I i, a and fide maintain oSomis.37W ofm a Laborrn to osis,four for Workers ce of the ,
mpon-
tion,as provided for mi Section 3]00 of Ne Labor Code,fm.the petfomuane of the
Work for which ills perms is issued.
)"YI have and will maintun Worker's C.old.is Insurance,h i.iM by gado.
3y of me LCo for des c err tfhework fmwhich mispermitisissued. ,
. an Wo Co motion Inmran putt end POI1cYanpyberme,
Ceriec ` 4-L PoIicY Na.Iv
ERT GATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This rection m a d nm be complered if me permit is fm me hued dollars($100)
or lac.)
I,any that in is my performance as to be .which this parrot is ins'C ishan ,
sell employ any Amon in any menmr m m to become subject th<Woelnn'Compen-. r
Applicant
NOTICE
of California,Dna -
APPlicant s -
NOTICE TO APPLICANT:If,after trading this Cmlficare of Exemption,you should -
become mbjacna the Wor me.Compensation provision.of me Labor Code,you mus,
-(onhwim comply with such providans err this permluhelf be domed rooked,
CONSTRUCTION LENDING AGENCY
p • IbertbywTlim ateterti>acs.,=donlendingagencyfmthepeffurmameof
rthe Work for Which this p Hnul 161ssued(Sac.3037,Civ.C.)
(� wr Lenders Name
ya > lander:Address
GT7 Q 1 moil"dust I have rend this application and spite that the above information is
eeeq....., correct.i agree to comply with all city and county umbers...and spite laws¢eating I.
U 0 building construction.and hereby su umes rtprcsmativea of this city to enter upon me _
W above-mentioned property for inspection purposes.
[... • (We)agree to save,indemnify and keep ham leas the City of Cupertino against 4 f ,
Q U luxulitiea,judgmema,costs and expenur which may in any way x1m1 Ismat said City
in conumusec of me granting of this permit t
E+ a' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
f..l z SOURCEREGULATIONS.
Signatumuf Applicaut Courector Date
HAZARDOUS MATERIALS DISCLOSURE oi>ale aV 7
Will dieeppeicaut or fumrt Wilding oxcupani sloven,handle hamdom material e- —9(S
'
as defined by the Cupertino Municipal Cade,Chapter 9.12,atm the Heald and Safety
Code,Section 255.32(a)9 Type of Roof
❑Yes
Will me applicant or future building occupon use wuipmen,or davima which All roofs shall be inspected prior to any roofing material being ,
emit harardour a4 contaminants as defaced by me Bay Arca Ab Quality Management installed. If a roof is Installed without £first obtaining an inspection
District?
❑Yea W - - I agree to remove all new materials for inspection. Applicant `
I have reed me hmsrdme matenda ni,dromamx mdc,Chager 6.95 of d¢Cali
understands and will comply with all non point source regulations.
(sortie Health&Sefety Code,Serums 25505;25533 and 25534.1 mMerstt d that if the
Wn c have a boon,mat it is my responsibility In wily Oa ettupant '
of is,m t 1 1 poorto
issmme of a Cenili cu
OwSignature of Applicant " Date
Data
All roof coverings to be Class"B"or better
OFFICE
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
BUILDING PERMIT INVOICE OPERATOR: katenb
•
Sec: Twp: Rng: Sub: Blk: Lot:31630105.00
INVOICE DATE......: 03/14/2000
REFERENCE ID # ...: 00030086
SITE ADDRESS .....: 10540 N BLANEY AV
SUBDIVISION .......
CITY CUPERTINO
IMPACT AREA .......
OWNER ............: NOLAN KATHERINE M
ADDRESS :.........:
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-2455
CONTRACTOR .......: ANDERSON, WILLIAM LIC # 5573
COMPANY ..........: DAHL PLUMBING CO, JOHN F
ADDRESS ..........: 329 ALMA ST
CITY/STATE/ZIP ...: PALO ALTO, CA 94301
TELEPHONE ........: 14151321-5500
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- --- --------- ------------ ----------- _
BREMAIRRAN P 8.33 0.00 8.33
BREMFURNOV P 14.43 0.00 14.43
BREMRECEPT P 1.11 0.00 1.11
EPERMITFEE P 35.52 0.00 35.52
MPERMITFEE P 35.52 0.00 35.52
--------- ------------ -----------
94.91 0.00 94.91
ve ID DESCRIPTION VOICE ID DESCRIPTION
........ ............................ -------- ......------------......----
303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL
505 FINAL ELECTRICAL 508 FINAL MECHANICAL
•
REiMACOVER JACUNIT >IGCOCCF%l INIEC-ANICAL
• mJ\ 119REMVENSYS
BREMAIRHAN JA/C UNITS <= 10,00CCFM IMECHANICAL
SRENIFURN RELOCATION OF FURNACE MECHANICAL
. BREMFURNOV IRELO FURNACE > 1CK BTU IMEC4ANICALBREMINH000 INSTALLATION OF HOOD MECHANICAL
BREMRELOCA RELOCATION OF HOOD NIECHANICALBREMREPALT REPAIR/ALTER HEATINGMECHANICAL IVENTILAT10N SYSTEMS MECHANICAL
PPERMITFEE JPLUMBNG PERMIT ISSUE IPLUMBING
2MSNUMULTI NEW MULIFAMILY RES IPLUMBING
BNUSFD NEW SINGLEFAMILY RES PLUMBING
BPBACKFLOW ATMOSPHERIC VACUUM PLUMBING
BPCESSPOOL CESSPOOL PLUMBING
BPFIXTURE PBLG FIXTURE PLUMBING
BPGAS GAS PIPING SYSTEM FEE PLUMBING
BPINTERCEP IND WASTE INTERCEPTOR PLUMBING
BPREPIPE IREPIPE OF FIXTURES PLUMBING
SPSEWAGE ISEWAGE DISPOSAL PLUMBING
BPSEWER SEWERS PLUMBING
BPSPRINK LAWN SPRINKLERIBACKFLO PLUMBING
BPSTORM STORM/RAIN WATER PLUMBING
BPTRAP KITCHEN TRAP IPLUMBING
BPVENT ALT OF DRAIN &VENT PLUMBING
BPWATER INSTALL/ALTER WATERPIP PLUMBING
BPWHEATER WATER HEATER/VENT PLUMBING
• BPWSVCS MAIN WATER SERVICE PLUMBING
ZDEVAGREE DEVELOPMENT AGREEMENT PLANNING
ZDIRTM DIR TENT MAP PLANNING
ZFULLHR FULLAPPLBASE+HR PLANNING
ZFULLTM FULL APPL TENT MAP PLANNING
ZFULLUP FULL APPL USE PERMIT PLANNING
ZFULLZONE FULLAPPLZONING PLANNING
ZGPAMEND GENERAL PLAN AMEND PLANNING
ZLIMAMENO LIMITED AMEND PLANNING
ZLIMTM LIMITED TENT MAP PLANNING
ZLIMUP LIMITED APPL USE FERMI PLANNING
ZMATEMPUP IMIN AMEND TEMP USEPERM PLANNING
ZMINHILLEX' MINOR APPL HILL EXC PLANNING
ZMINSIGNEX M'SC SIGN EXCEPTION PLANNING
ZMINTM MINOR APP TENT MAP PLANNING
ZMINUP MINOR APPL USE PERMIT PLANNING
ZMISCASA MI
ARCH S PLANNING
ZMISC MISC AND UP PLANNIN
ZMIS FENCE MISC FENCE EXCEPTION PLANNING
' ZMISCGEN MISCELLAPPLGENERAL PLANNING
ZMISCPCINT MISC PC INTERPRETATION PLANNING
ZSIGN SIGN PERMI PLANNING
ZTEMPSIGN TEMPORARY SIGN PLANNING
VARIANCE DIRECTOR VARIAN PLANNING
• 2 oC2
. Re+itad Ll099
Dry. i/ Applicable Fee ID Fee Description Fee Group
ISPERbIFEE BLDG PERMIT FEES BUILDING
IBCONSTAX 1CONSTRUCTION TAX ISUILDING
jBENERGY JENERGY BUILDING
ISENERGYAOD ENERGY A00 MULTI BUILDING
1BOVERTIME INSPECTION OVERTIME BUILDING
BTEMPPERM TEMPORARY BLDG PERMIT BUILDING
BMITIGAT HOUSING MITIGATION FEE BUILDING
JBPLANCHK PLAN CHECK FEE BUILDING
BPLANCKADO PLAN CHECK ADD MULTI BUILDING
BPLANCKREP PLAN CHECK REPEAT FEE BUILDING
BREINSPECT REINSPECTION FEE BUILDING
BSCBLVD SCS SPECIFIC PLAN BUILDING
BSEISMICOM SEISMIC COMMERCIAL BUILDING
BSEISMICRE SEISMIC FEE RES BUILDING
ESPECIAL SPECIAL INSPECTION IBUILDING
BSWIM SWIMMING POOL BUILDING
ZAODCHG ADDRESS CHANGE SUILOING
EPERMITFEE ELEC PERMIT ISSUANCE ELECTRICAL
BELEC1000 ELEC 600V <=1000A ELECTRICAL
BELEC1001 ELEC 600V>1000A ELECTRICAL
BELEC200 ELECT SVCS 600V c=200A ELECTRICAL
BNEWMULTI MULTIFAMILY RES ELECTRICAL
BREMBUSWAY REMODEL BUSWAYS ELECTRICAL
MBR
EMFIXT LIGHTING FIXTURES ELECTRICAL
EMMISC MISC APPARATUS ELECTRICAL o
EMNRAPP REM NON-RES APPLIANCE ELECTRICAL
EMPOLE POLEIPLATFORM FIXTURE ELECTRICAL
EMPOWER POWER OEVICEIAPPARATUS ELECTRICAL
EMRECEPT RCPTL, SWITCH &OUTLETSELECTRICAL
EMRESAPP REMODEL RES APPLIANCE ELECTRICAL
EMSIGNAD RMOL SIGNS ADO BRANCH ELECTRICAL
EMSIGNS REMODEL SIGNS, MARQUEE ELECTRICAL
EMTHEATR THEATRICAL LGHTNG FIX ELECTRICAL
F&2FAM SINGLE&2 FAMILYELECTRICAL
EMp TEMPORARY POWER ELECTRICAL
BTEMPSVCS ITEMP DIST SVCS ELECTRICAL
MPERMITFEE MECH PERMIT ISSUANCE MECHANICAL
BAPPLOTHER OTHER APPLIANCES MECHANICAL
BBOILERI BOILER� 100,000 BTL IMECHANICAL
BBOILER2 BOILER>t00KTO500KBTU MMECIMICALAL
BBOILER3 BOILER>500K TO 1M BTU CAL
BBOILER4 BOILER>1M TO 1.75M BTU CALBROILERS BOILER> 1.75M BTU CALBREMAPPU APPLIANCE INSTALL CAL H INS ALLATION CALBREMVENFAN VENT FAN SINGLE DUCT CALBMNEWMULTI NEW MULTI-FAMILY RES CALBMNEWSF&2F NEW SF&2F RES SLOGS CAL
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