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991201111 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL, BUILDIMRDIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL. BUILDING PROJECT IDENTIFICATION BUILDINGA 7 SS: SANITARY NO. APPLICATION SUBMITTAL DATE /0 S. r'3 OW ER'S NAME: PHONE: 'fR CTOR'S Is14M LIC NO: O/[I N/C CONTROLN ARCHI 'T NGINEER: LIC NO: ADDRESS: ❑ - 3 S E./1 01aei CONTACT PxoNE: BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUM MECH ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESC I Aa0 with Section]000)of Division 3ofth,Businessman Professions Code,and my license is RESIDENTIAL: W O PERMI'C ISSUANCE NuNuF W I. m fall lass eRect. ❑SEPAL ❑KITCHE EMOUEL License Class Liak APPLIANCES-RESIDENTIAL El ADDITION ❑PLUMBING REPIPE GW Date Contractor ARCHITECT'S DECLARATION El MULTI-UNIT El STRUCTURAL SFOOZ I understand my plans shall he used aspublicme.ods PANELS MODIFICATION CZ4, OTTO 200AMPS El INTERIOR El CHIMNEY REPAIR W Licensed Professional 201-100DAMPS IMPROVEMENT E]SWIMMING POOLS OWNER-BUILDER DECLARATION OVER 1000 AMPS - [I BATH REMODEI✓REPAIR DEMOLITION a 1 hereby.(Seco on 1 1 S exempt from the Contractor's License Law for the O0.V following reason(Section Ton 5,Business andimprove, ve,deainns h,or Any city os enuntY SIGNS ELECTRICAL C,OTHER 3 u vF which requires n permit rete construct,alcor,improve,Aemuliftt m aito,any structure �O¢ prim mitcensed pursuant requires the ovisio ant forsofthe such Contractors micas,Loword SPECIAL CIRCUIT/MISC. that hej+0 hover pacin,with pSetio7000)ofDisiansof the Contractor's License Law(Chapter9 W Q� (hat he engwith Secfromandth basis,n3 oftheegeBusiness xempt Professions Code)or TEMP.METER OR POLF.INST. COMMERCIAL: Sec he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION iC t� Section 70315 by any applicant for a permit nuhjects the applicant to a civil penahy of POWER DEVICES W^h ❑TENANT ❑FOOD SERVICE > not more than five hundred ty,dollars yempl. IMPROVEMENT 2Fd ❑ Lo the work,the property,or myemntendes with wages forrastheir(tie compensation, SWIMMING POOL ELECTRIC {..q will dmhe,two,and the The Concure is tors License offered do.no, ..1,See 1.im Business W 6C m and Pndeaaians Cede:The Contractors License Law Anes nal apply m an at,of OUTLETS-SWITCHES-FIXTURES Q' .. property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ EF sole.If,however.Bar building or improvement is sold within one yearofecmpletian,the SQ.FT.FLOOR AREA $/SQ.FT, owner-builder will have the burden of proving that he did not build or improve for put pose of sale.). E] 1,as owner of the property,an exclusively contracting with licensed contractors to TO construct the project(Sec.7044,Business and Professions Code)The Contractor's Li- cense Use does not apply an ma owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT who exqurmis for such projects with a amtramm(s)licensed pursuant to the Contractors 00, License Law, E)I am exanpt under Sec ,B&P C fonbis mason PERMIT ISSUANCE Owner Dam ALTER-DRAIN&VENT-WATER(EAI. VALUATION WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 1 hereby affirm under penalty of perjury one of the following declarations: ]I have and will maintain a CmifictilumConsentmself-Insure for Worker's Cmnpen- DRAINS-FLOOR,ROOF AREA,COND. STORIES TYPE CONSTRUCTION ation,as provided for by Section 37110 of the Labor Cade,for the performance of the ..,it for which this permit is issued. FIXTURES-PER TRAP ❑I have and will maintain Workers Compensation Entrance,as required by Section 3900of Ne Labor Code,forthepedo once of the work for which this permit ie issued. GAS-EA.SYSTEM-IINCAOUTLETS OCC GROUP APN . My Worker' rm nsasi nlnsuran .,letandPollynumncr are;_ l Cartier. Pond Palo.; GAS-EA.SYSTEM-OVER 4(EA) 11�3�0 CERTIFI ATE OF EXEMPTION FROM WOR ERS' l!/ COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FPRS This section need nnthearmpleted ifthepeemlt is for one hundred dollars($IDD) GREASE'fRAP or less.) PLANCHECK PEE Loy any thatinthe paywi anro as t work for which Nis the ut Workers ed SabahCoin.- SEWER-SANITARY-STORM F.A.200 FT. not employ any person In any manna so as m became thjuun the Workers'Cnmpen- ENERGY FEE Z satlon taws of California.Date WATER HEATER WNENT/ELECTR O Applicant 1 WbING FEE y NOTICE TO APPLICANT:If,after making this Certifiers,of Exemption,you should WATER SYSTEM/IREATING become subject to the Worker's Compensation provisions of the Labor Code,you most FEE Wforthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE a � .� z the CONSTRUCTION LENDING AGENCY NEW RESIIJEN'I'IALPLMR. SQ.FT. ID� Receipt# L)0 Iherchy affirm tharihere isacanswetion lenAing agency far performance of ;Isshe work for which this permit is issued(Sec.3099,Civ.C.) C) LendexName - TO U Lenders Address TOTAL. (3UELDING FEE It 1 certify that 1 have read this application and state that the above information is LI) correct.I agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE SEES U building construction,and hereby authorize representatives of this city to enter upon construction, the IC`F above-mentioned property for inspection purposes. PERMIT ISSUANCE (We)agree to save,indemnify and keep harmless she City of Cupertino against ELECTRIC FEE liabilities,judgments,costs and expenses which may in any way accme against said City ACPER OR ADD TO MECH. in consequence of the granting of this Permit. PLUMBING PEE APPLICANT STANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IB,001)CFM) SOURCE 1 l �p MECHANICAL FEE �,{/�J'"� g AIR HANDLING UNIT(OVER Iff"CPM) CONSTRUCTION TAX SI cam Applic oamu Data EXHAUST HOOD GVMUCT) HOUSING MITIGATION FEE HXZAaV6US MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material HEATING UNIT TO 100,000 BTU) as defined by the Copeman Municipal Cade,Chapter 9.12,and the Health and Safety - Code,Seen..25532(x)9 HEATING UNIT(OVER 100,000 BTU) ❑Yes []No VENTILATION FAN(SINGLE RESID) PAID Ont Receipt# Will the air contaminants or furore definedding occupant use equipment or devices which BOILER-COMP OFF OR 100,000 BTU) it hazardous air comaminams as defined by she gay Arca Air Quality Management TOTAL: Ile 7 lyes No BOILER-COME(OVER 100,000 BTU) �V( IR CONDITIONER I have read the hazardous materials requirement under Chapter 6.95 of the Cali- AISSUANCE DATE , comma Health&Safety Cade,Sections 25505,25533 and 25534.1 underxtand Wm if the NEW RESIDENTIAL,MECH. SQ.Fn building does not annually have a tenant,that it is my responsibility to notify the ocwpanl of the requiremenw which most be mm pd.,to issiterve of a Ceniflmm of Occupwey. Owner or authorized agent - Data TOTAL: ISSUED BY: OFFICE INVOICE• INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE CITY OF CUPERTINO • BUILDING PERMIT INVOICE OPERATOR: Yvonnek Sec: Twp: Rng: Sub: Blk: Lot:31634028.00 INVOICE DATE. . . . . . : 12/20/1999 REFERENCE ID # . . . : 99120111 SITE ADDRESS .... . : 10551 N BLANEY AV SUBDIVISION ...... . CITY . . . . ......... : CUPERTINO IMPACT AREA ...... . OWNER . . . ......... : FRIESON DOUGLAS L ET AL ADDRESS . . . .. . . ...: CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-2454 CONTRACTOR ....... : LIC # COMPANY . . . . . ..... : ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . , TELEPHONE . . . . . . . . : NOTE: THE FEES LISTED ARE ONLY THOSE DUE BEFORE PERMIT PRINTING FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE --------------- --- --------- ------------ ----------- BPWHEATER P 9.99 0.00 9.99 PPERMITFEE P 35.52 0.00 35.52 --------- ------------ -- 45.51 0.00 45.51 10 ID DESCRIPTION VOICE ID DESCRIPTION 6IIE === =Lam c502 FINAL PLUMBING ENERGY 506GAS TEST L=====__ - Eg 507 FINAL PLUMBING •