00010022 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY Q O 0 Z
CITIV OF CUPERTINO BUILDING-ELECTRICAL E
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MRCIIANICAI.
�.� BUILDING PROJECT IDENTIFICATION
BUILDING SANITARY N0. APPLICATION SUBMITTAL DATE
111,,VWa^s/
ER�NAM-Ef. �PH_ : CO AL70Ro'S NAME: ` LI NO:
NIC CONTROL
11 p
CHITECTIINGINEER: LIC NO: ADDRESS: ❑
CONTACT. PHONE: BUILDING PERMIT INFO
nk
1 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MEC e, krysik
5�b X90 -SSSS ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby uffrm Nat 1 am on
licensed under provisis of Chapter 9(commencing JOB DESCRIPTION
MWZwith Scction 7000)of Division 3 ofthe Businessand Professions Cole,andmylicense is RESIDENTIAL:
WOO PERMIT ISSUANCE
FUZUW infill fo-ewd=Rat ❑SFDWL EI KITCHEN REMODEL
U U Licen. Crux Lic.p
tFir6a�vo Dam Comtxmr APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RF,-PIPE
ARCHITECT'SDF,CLARATION =TIL PANELS ❑MULTI-UNIT ❑STRUCTURAL
ZO`°Z lundentandmyplans,hallbouudaspublicrecords - MODIFICATION
OZ— UPT02MAMPS ❑INTERIOR ❑CHIMNEY REPAIR
F N.,F.W Licenced Pmreoduced 201-1001AMPS IMPROVEMENT SWIMMING POOLS
y OWNER-BUILDER DECLARATION OVER IOO)AMYS ❑BATH REMODEUREPAIR ❑DEMOLITION
�J GC w� 1 hereby affirm that I am exempt from the Contractor's License Law for the
X 3 a U following reason.(Section 7031.5.Business and Profession Code:Any city tar dant, SIGNS ELECTRICAL ❑OTHER
F-K O y which requirts➢permit IU ConFlNtI.eller,improve,demolish,or ret in any some n e
prior to its issuance,also requires the applicant forsuch permit to file a signed statement SPECIAL CIRCUMMISC.
�,`((jthat he is licensed pursuant to the provisions of the Contractor's License law(Chapter 9
�aa�p0 (commencing with Section 700)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST -0 MC M FACIA11
that he is exempt theretrnm read the basis for the alleged exemption.Any violation of ❑NEW BLDGIADDITION []DEMOLITION
�m Section 7031.5 by any applicant for o permit subjects the applicanuo a civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
not more than Eve hundred dollars(5500),
F Z_Y IMPROVEMENT
Q ❑Lasthe work.the Property.or i, employax...ofered as their sole 0v,LB sineson, SWIMMING POOL ELECTRIC
O will duthewons ande: o rtme Contractor's
tended License La does of apply 7U W,Business []OTHER
3� and Professions Cale:The Corrector's License Law dcex not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himselr or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT
side.If,however,the building or improvement i,mId arum neycmrof completion,the 01 SQ.FT.FLOOR AREA SISQ.FT.
neobuilder will have the burden of proving that he did not build or improve for pur-
pose of sale.).
EI 1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
instruct the project(Sec.7044,Business and professions Code:)The Cmmraclors Li
cense Taw does not apply to an owner of pr^pcny who builds or improves thereon,and QTY. PLUMBING PERMTF
who contacts lar such projects with a contruaor(s)licensed pursuant to the Command's
License Law, PERMIT ISSUANCE
I am exempt under Sec. ,It&P C for this reusm
_ Done, Date ALTER-DRAIN&VENT-WATER ILII VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I herebyaffirm under affirunder penalty of perjury one of Ne following decimations:
FI I have and will maintain a Certificate of Conseil in self-umre for Workers Comped- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPECONSTRUCION
cation,as provided for by Section 37M of the Labor Code,for the performance of the
Zfor which this permit is issued. FIXTURES-PER TRAP
have and will maintain Worker's Compensation Insurance,as required by Section
of the labor Code,far me performance of the work
�to,
wwhichthis peorm,isis issued, GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUT' LAPIN-1
My Wmr P�l�9il n^C�n °J�olcy No.yV✓ �th —,�--�o GAS-EA.SYSTEM-OVER4(G) V /Q
Carver
E TIPICATE OIE%EMI'TION FROM WORKERS' GREASFIINDUSTRL WASTE INTERCEPTOR COMPENSATION INSURANCE - -
BU1L01NGUIVISIONFEGS -
(This ucuon red no becompldWirthe p:rmit is furore hundred dollar,(EI W) GREASE TRAP
or le".) PLANCHECK EEE
I certify Nal in the perfamunce of the work for which duspermit is issued,l shall SEWER-SANITARY-STORM RA.201 PI'.
not employ any person in any runner so as to become subject to the Workers'Compen- ENERGY FEE
,z cation Laws of California.Date WATER HEATER WNENT/ELECTR
O Applicant GRADING FEE
h NOTICE TO APPLICANT:IE after making this Certificate of Exemption,you should WATER SYSTEM/TREATING
become subject to the Workers Compensation Provisions of Use labor Cole,you must SOILS FEE
forthwith comply vim,mam provisions or this per mit shall he deemed revoked. WATER SERVICE
aQ
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMIt. SQ.FT. PAID ��-
V0I hereby affirm thatdareis a construction lendinginamey for the performancemf Dm Rc,ciptp
Ns work for which this permit is issued(Sec.3097,Civ.C.) ���'---
W U Lender,Name i l ea l /A.\ TOTAL: -�
V Ismer,Addrtss TOTAL:
f47 1 certify that I have road this application and state that the above information is BUI 446 FEE V `A U
rs e�A correct l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U Z building construction,and hereby amboric,representatives of this city m enter upon the SEI.SNIICFEJ
aN,,r-mentioned Property for inspection partum, PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELVRIC FEE
liabilitiex.judgmema costs and expenses which may In any way same against said City ALT ER OR ADD'IO MECH.
in onaequence of he granting of this .it. PLyMBMG FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.010 CFM)
SOURCE QT',GUL TI- !k Olt[, CONSTRUCTION
FEE
70SU'�,\]�`�{X� _ AIR HANDLING UNIT(OVER IO,OW CFM) CONSTRUCTION TA% A�
Sig cof plicanuCmareclo Dale EXHAUST HOOD(W/DUCq
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or furore building occupant stare or handle hazardous material HEATING UNIT(TO 100.01)BTU)
as dented by me Cupcnimu Municipal Calc.Chapter 9.12,and the Health and Safety
Cede.Section n532(a)7 HEATING UNIT(OVER 100,000 BTU)
El Yea E]No PAID
VENTILATION PAN(SINGLE RESID) Date Receipt p
Will the applicant or Tuts building occupant use equipment or devices Management
Dbuic zvdmus air conlamirwnH as defined by the Bay Area Air Quality Management BOILER-COMP(JHP OR 144.(100 BTUI
TO fAL:
Dixtrici!
❑Yes No BOILER-COMP(OVER 100.(X10 BTU)
❑ ,
I have real the hazaNeu,matcridls requirements uMcr CTup¢r 6.95 of the Cali- AIRCONLHITONER
ISSUANCE DATE
humid Health&Safety Code,Sections 25505.25533 and 25534.1 undersand that if the NEW RESIDENTIAL MECH. SQ.E.
building doe not cumn0y ve a ummt that it is my resporehiloym modify the ceempare .—Zv 0P
ofthe s el proraissmanceofaa teof Occu�Q9\Ky ( V
Own mhorimcd ugem Dia TOTAL: i ISSUED BY:
OFFICE
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
BUILDING PERMIT INVOICE OPERATOR: karenb
Sec: Twp: Rng: Sub: Elk: LOC:35618049.00
INVOICE DATE......: 01/06/2000
REFERENCE ID k ... : 00010022
SITE ADDRESS .... . : 21662 COLUMBUS AV
SUBDIVISION ...... .
CITY ... . ...... .. . : CUPERTINO
IMPACT AREA ...... .
OWNER ... ......... : KNOCK RICHARD T AND LINDA J TR
ADDRESS .. .. ......:
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-4711
CONTRACTOR .......: ALTON, MICHAEL LIC # 21326
COMPANY ..........: ALTON AIR CONDITIONING R HTG
ADDRESS . . . .......: 45300 INDUSTRIAL DR #4
CITY/STATE/ZIP ...: FREMONT, CA 94538
TELEPHONE . .......: (510)490-5655
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- --- --------- ------------ ________-__
BREMREPALT P 12.21 0.00 12.21
MPERMITFEE P 35.52 0.00 35.52
______ ____________ ___________
47.73 0.00 47.73
DESCRIPTION
V ID ..... ........... ........ VOICE ID DESCRIPTION
. .. ........ ...... .............
9 UNDERFLOOR FRAME 301 ROUGH PLUMBING
303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL -
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL 514 FINAL PUBLIC•WORKS