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99100060 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY Q O 'O CITY OF CUPERTINO BUILDINGELECTRICALx PERMITN . BUILDING DIVISION APPLICATIONIPERMIT PLUMBING MECHANICAL COoo� BUILDING PROJECT IDENTIFICATION O BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE WNE 'S NAME: C1 PHONE R CO CT(lR'S NA O LIC NO: IF�K.J'• in �L NIC CONTROL# 11F113 OJ4 Clult GI LIC I � DRESS ❑ 4- 4oldAf c u CONTACT: PHONE: Vhj BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH SSA , ( ❑ ❑ .Dd- ❑ LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing _ JOB DESCRIPTION CTaz ffiSectiontWO)of Division 3yFth D 1 dprofessions Code and yl'cense is PERMIT ISSUANCE RESIDENTIAL' �r I.Urri sClas, affamG / _e ir.#'es �y m t DSFDWL ❑KITCHEN REMODEL, UZ U Licenxe Class t� Lic.# 'S T y6 Date Camranw .�.+ APPLIANCES-RESIDENTIAL EIADDITION ❑PLUMBING RE-PIPE z Oyy ARCHITECT'S DECLARATION /1�iL/� PANELS ❑MULTI-UNIT El STRUCTURAL r�❑ [understand my plans shall he used as public records fC.MM��" /J MODIFICATION Oz`r - / UPTO 200AMPS - F.N.I"Q Licensed Professional 201-1000 AMPS ❑INTERIOR El CHIMNEY REPAIR q�ya .'IMPROVEMENT V OWNER-BUILDER DECLARATION SWIMMING POOLS Yi C9.I 1 hereby affirm that 1 em exempt from the Comracmrs License Law for the OVER 1 WO AMPS f, a ❑HATH RE DEMOLITION ❑DEMOLITION 3 0.F following reason.(Section]031.5,Business and Professions CWe:Any airy or county SIGNS ELECTRICAL ❑OTHER U1.4' �- a�B�t1T9 2 O mi which requires a pert it)construct, repany consct,alter,improve,demolish,or air an structure F.,u„ - i._1J2 LarC/L.l�✓T to its issuance,also requires thesuch Permit file tosigned em SPECIALCIRCUITMISC. that he islicensed pursuant to the provisions oftheContrasted,License Law(Chapter 9Woo (commencing with Section 7")of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INET. COMMERCIAL' that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION W m m Section 7031.5 by any applicant for it Permit subjects the applicant to a civil penalty of POWER DEVICES [F.. p. not more than live hundred dollars($5007. �TBNANT LJ FOOD SERVICE q�6 I,as concoct the n,nrm em to ecs with wa es as Ncir sole cont tion, SWIMMING POOL ELECTRIC IMPROVEMENT ii22YY 0 ❑ Press structure Y P Y 6 penes II Jo the work,and theheCo is not x Liiens proffered for sale(Seap,[,to im Business, ❑OTHER m and property wh b Code:The Cos there's License Lou does not apply sen owner of OUTLETS-SWITCHES-FIXTURES .. property who builds or improves thereon,and who noes such work himselforthrough his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECI'R SQ FT. s""^ gale.If.however,the building or improvement is sold within one year ofeempleion,the Q.FT.F1{7�$AREA .FT. owner-huilder will have the human of proving that he did not build or improve for pur- ^ L��(��, �' pose of eels.). - r U ❑ 1,a owner of the property,.B exclusively contracting Cod :)The nnecto's i- AL: construct the project(Sac.TI144,Business and Profusions ds or The Gmh�ereon,and � x - Ov l 1999 whoa Law dyes not apply to an owner of property who builds or improves thereon.and QTY. PLUMBING PERMIT FEE �I 1 who contracts for such projects with a convector(s)licensed pursuant to the Contractor i License Law. / PERMIT ISSUANCE ❑lam exempt under Sec. ,B&P C for this reason Date ALTER-DRAIN&VENT-WATER(EA) ✓ate TION neo WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 1 hereby affirm under Penalty of pe,in, an of the following declarations: I have and will maintain a Certificate of Consent to self-insure for Workers C.mpen- DRAINS-FLOOR,ROOF,AREA,COND. anion,as provided for by Section 3900of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION work for which,his permit is issued. FIXTURES-PER TRAP ❑I have and will maintain Worker's Compensation Insurance,as required by Section - - 30011oftheLaborCode,fonhe performance of the work for wM1ich this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP - APN Myler: QompeJyatlgp�l(Iur�qge carrier olicy No.and �nu�I ya4265''Z. GAS-EA.SYSTEM-OVER4(EA) ]� Carrier: 'f%MTI �� E _WO /RS' CERTIFICATE OF EXEMPTION FROM WOR CERS' GREASF/INUUSTRL WASTF,INTERCEPTOR ' I COMPENSATION INSURANCE BUILDING DIVISION PEES (This "section rte not he o Iced if the permit is forone hundred Dollars($1 W) GREASETRAP.or las.) . PLANCHECK FEE -,certify peers Thep ancenf the work for which this permit ie issuW,lshall SEWER-SANITARY-STORM F.A.200 FT. not employ any person' mercer sn as nr hec'JJ'��e suyg t�f o kers'Compen- ENERGY PCE O z Numa Laws of Calif If (r}'/�7 r WATER HEATER WHEN VELECTR Applicant GRADING FEE I-i t NOTICE P ANT:If,ager making this Cenifieme of Exemption;you should WATER SYSTEMII'REATING (~ l become subject to the Worker's Compensation previsions of the Labor Come,you must SOILS FEE Wforthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE Q � z CONSONLENDING AGENCY NEW RESIDENTIAL FILMS. SQ.FT. PAID - V hereb2 1y aBLrm that thereem iissaconstruction lending agency for the of Dare .ReceiptN w H k for which this permit is issued(Sec 3099,Civ.C.) 0 U Lender's Name - TOTAL: W Lenders Address TOTAL: I certify that I have read this application and site that the above Information is BUILDING FEE in comet.L agree in comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT a FEE V building contraction,and hereby suborive representatives of this city to enter upon the SEISMICFEE above-mentioned property for inspection purposes. PERMIT ISSUANCE (We).9.t.sax mo and keep harmless the City of Cupertino against ELECTRIC FEE liabilities,judgments, stsundexn bh may in any way seem,against said City ALTER OR ADDTO MECH. in consequence ofthe arcing noir. PLUMBING FEE APPLICANT UNDER NO WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000CFM) . SOURCE REGULATIO - MECHANICAL FEE _ AIR HANDLING UNIT(OVER 10,01DOCFM) CONSTRUCTION'fA% Signatmreof ApplicarnUmemcmr Dare EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Will theapplitam in fare,,building rwcup.nt same or handle bcaria emnterial HEATING UNIT(TO 100.000 BTU)' as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code,Section 25532(a)R HEATING UNIT(OVER 100,000 BTU) ❑Ys ef< PAID VENTILATION FAN(SINGLE RESID) Date Receipt# Will the applicant or future building occupant use equipment or devices which , it hazardous air ememarnams m defined by the Be,Area Air Quality Management BOILER-COST(THE OR 100,000 BTU) OTAL. Yes strict' 1_�/' BOILER-COMP(OVER 100,000 BTU) ❑ I h.an the hoz d Mels requlremut undu chapter 6.95 of the Cali- AIR CONDITIONER - ISSUANCE DATE fomia HUIN Safe .S tan 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL.MECH. SQ.FT. huildingdees ice at ea mnm,rhmi[is my responsibility,.notify the occupant of the require is mast ha and prior to issuance'of a Certificate of Occupancy - Owner or m oozed agent - Date TOTAL: ISSUED BY: OFFICE ;A-E0" CERTIFICATE OF LIABILITY INSURANC ;ID GB GATE(MMroDWATER-1 04/19/99 CER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE ner Insurance Brokers HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 0 Willow Road, Suite 250ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. aanton CA 94588ne: 925-463-9672 Fax:925-463-0192INSURERS AFFORDING COVERAGE ED INSURER A: State Compensation Ins. Fund INSURER B'. Water Heaters Only, Inc. INSURER 500 tCA1946105te 24OINSURER D'. I INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE POLICY NUMBER DATE MM/DD DATE MM/DD LIMBS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY FIRE DAMAGE(Any ane fire) S CLAIMS MADE F7OCCUR MED EXP(Anyone person) $ PERSONAL 8 ADV INJURY $ GENERAL AGGREGATE $ GEN-L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 17 POLICY PRO- LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) S ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) S HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE S (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACAGL g AUTO ONLY: E S EXCESS LIABILITY EACH OCCURRENCE S OCCUR E CLAIMS MADE AGGREGATE S S DEDUCTIBLE S RETENTION S WC TU 'HS WORKERS COMPENSATION AND X TOO LIMBS I ER A EMPLOYERS LIABILITY 151626598 04/20/99 04/20/00 E.L.EACH ACCIDENT 51,000,000 E.L.DISEASE-EA EMPLOYE E 1,OOO,ODO E.L,DISEASE-POLICY LIMIT E1,000,000 OTHER DESCRIPTION OF OPERATIONSILOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS All California operations 1J CERTIFICATE HOLDER H I ADDITIONAL INSURED;INSURER LETTER: CANCELLATION CIIFER-1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS W RTTTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE City of Cupertino 10300 Torre Ave LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITYOF Cupertino CA 95014 ANY KIND UPON TH S BER,ITS AGENTS OR REPR= ATIVES. Jane Ann e ACORD 25-S(7/97) " ACORD CORPORATION 1985 CITY OF CUPERTINO 1 Of 1 BUILDING PERMIT RECEIPT OPERATOR: chrlaCya COPY # 1 Sec: Twp: RnS: Sub: Blk: Loo:31642002.00 DATE ISSUED. ......: 10/12/1999 RECEIPT #.........: 10311 REFERENCE ID # ...: 99100060 SITE ADDRESS .....: 20263 CARTWRIGHT WY SUBDIVISION ....... CITY .............: CUPERTINO IMPACT AREA ....... OWNER ............: FISCHER GAY A ADDRESS ..........: i� CITY/STATE/ZIP' ...: CUPERTINO CA, CA 95014-2227 RECEIVED FROM ....: ALAN CONTRACTOR .... ...: MCGEE, PAT LIC # 18986 COMPANY .... ...... : WATER HEATERS ONLY ADDRESS ..........: 500 AIRPORT BLV CITY/STATE/ZIP ... : BURLINGAME, CA' 94010 TELEPHONE ........ : (415)349-3747 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW HAL __________ _____________ __________ __________ __________ __________ __________ BPW -_-___ ______ HEATER PER HEATER 1.00 9.99 0.00 9.99 0.00 TFEE FLAT RATE 1.00 35.52 0.00 35.52 0.00 PERMIT 45.51 0.00 45.51 0.00 P OF PAYMENT AMOUNT NUMBER ___________ ____________ __________________ CHECK 45.51 47179 ............ TOTAL RECEIPT 45.51 VOICE ID DESCRIPTION VOICE ID DESCRIPTION ........ ............................ ........ ............................ 106 SEWER 6 WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 302 TUB 6 OR SHOWER 502 FINAL PLUMBING ENERGY 506 GAS TEST 507 FINAL PLUMBING -r INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE CITY OF CUPERTINO BUILDING PERMIT INVOICE OPERATOR: christYa Sec: Twp: Rng: Sub: Elk: Lo[:31642002.00 INVOICE DATE......: 10/12/1999 REFERENCE ID M ...: 99100060 SITE ADDRESS ..... : 20263 CARTWRIGHT WY SUBDIVISION ...... . CITY ............ . : CUPERTINO IMPACT AREA ....... OWNER ............ : FISCHER GAY A ADDRESS .... . .....: CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-2227 i CONTRACTOR ....... : MCGEE, PAT LIC # 18986 COMPANY .......... : WATER HEATERS ONLY ADDRESS ........... : 500 AIRPORT BLV CITY/STATE/ZIP ... : BURLINGAME, CA 94010 TELEPHONE ........: (415)349-3747 FEE DESCRIPTION CHR 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 VID DESCRIPTIONVOICE ID DESCRIPTION. ............................ a . ...... - --- - -------- SEWER & WATER 202 UNDERFLOOR PLUMBING . 1 ROUGH PLUMBING 302 TUB & OR SHOWER 502 FINAL PLUMBING ENERGY 506 GAS TEST 507 FINAL PLUMBING r'