99120089 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
Cl4'Y OF WPF.RTINO BUILDING-ELECTRICAL ER IT Ncom O.
RUILDINGDIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
IiU1LDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT'2 901 /v v c Z.-
WNER'SNAME: PHONE: CONTRACTOR'S NAME: !1.2LIC NO:
L NIC CONT Ol p
CHITI?CT/ENGINE hlU LIC NO: ADDRES ❑
S
CONTACT: PHONE: BUILDING PERMIT INFO
__6y-, , ❑ Consultant Fees Paid by Applicant(Initial) B1 DO ELECT r1.uMH MI
V ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION Q'TY. ELECTRIC PERMIT FEE JO
DESCRIPTION
IPTION
O C Z I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
with Section 7")of Division 3 of the Business and Professions Cole,and my license is RESIDENTIAL
f+1 O_p PERMIT ISSUANCE
F in full force and,Rest. ❑SFDWI. El KITCHEN REMODEL
�UF License Class Lich APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-
PIPE
FZZW Date
Contractor
w6a
El MULTI-UNIT ❑STRUCTURAL
ARCHITECTS DECLARATION
PANELS MODIFICATION
Z p-Z I understand my plans shell be used es public mcaMs
OZ�Q UP T020f1AMP5 INTERIOR ❑CHIMNEY REPAIR
Licensed Professional 201-1000AMPS IMPROVEMENT E3 SWIMMING POOLS
OWNER-BUILDER DECLARATIONOVER If100 AMPS ❑BATH REM(Jj UR PAIR DEMOLITION
yy9a W Q I hereby alftrm that 1 am exempt from the Camracmrs License Law for the 7S' h
W 36 U following mason.(Sermon]031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER r „/lE/' 7�✓a
t1. LL which inquires a permit to cnruwr,alter,improve,demolish,or repair any swcwre CYVJ (rG)
f LL04, Near torn issuance.also declaims the applicant for such Permit to file a signed statement SPECIAL CIRCUIT/MISC. ��p•f L//j}
y} that he is licensed Pa....,1.he Provision,of the Cmadmaes License lsw(Chaptm9
Gf (commencing will Section 700fol Division Jot the Basin,,,and Pmfessions Cole)car TEM P.METER OR POLE INST. OMM R IAL'
L q
CC)
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
W-y Section 7031.5 by any applicant fora permit subjects the applicant In.civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE.
sOnot more than five hundred dollam($501). IMPROVEMENT
0 Las owner of the property,or employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
p. will drthe work,and natatorium,I,not imandcdorotiered Rusale Xce.'/040,Business DOTHIiR
i 3 and Professions Code:The Commewev License Law does not appy to an awncr of OUTLETS-S W ITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself in through
his own employees,provided that such improvements am not intended or nlTered for NEW RESIDENTIAL EL[CfR 5Q FT.
nate.IL however,the building or improvementis sold within one year ofemoplefothn.the SQ.FT.FLOOR AREA $ISG.IT.
ser-builder will have e buNen of Proving that he did not build or improve far pur-
"ve of sale.).
C]1,as owner of the property,am exclusively contracting with licensed o-mtemam to TO
construct the prajawl(Sec.7004,Business and Promilho s Crde)The Contractors Li-
cameWwdoesactapplytoanownerofpropertywhobuiksorimprovesthereon,and QTY. PLUMBING PERMIT
who contracts for such projers with a conoachms)licensed pursuant to the Commctnr's
License Law, PERMIT ISSUANCE
❑ism exempt under Su. ,B&P C for thamaor
net Date
ALTER-DRAIN&VENT-WATER LEA) VALUATION WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE. / 3 TO
I hereby efEatm under penalty of pe jury one of the fallowing declinations: 1
*01
a and will mvnmineCmifica¢of CnpsenuaCode,surefer Workers Campers- DRAINS-FLOOR,ROOTS AREA,COND. STORIES TYPE CONSTNUCfI01
smirk,us Provided for by Section 7]00 of the Lahr Code,for the petfomancc of Ne
work for which Ibis Pressor is issued. FIXTURES-PER TRAP
1 have and will maintain Workers Compensation Insurance, required by Section
3700 of the lsbor Cuxle.for the performance of Ne work for whichh this Permit vibrated. GAS-EA.SYSTEM-1 INC.4OUTLETS OCC GROUPPPN
My Worker'a Compensation Insurance cancer and Policy number art: Ip
Cartier: Policy Na: GAS-EA.SYSTEM-OVER 4(EA) S r
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASNINDUSTRL WASTE 1N'DiRCEFFOR r i
COMPENSATION INSURANCE BUILDING DIVISION FEES _
(This section need not be completed ifthe permit is forone hundred dollars($End GREASETRAP
PLANCHECK FEEor less.)
I certify that in the performance of the work for which this permit is issued,,shall SEWER-SANITARY-STORM EA.20al FT.
not employ any person a in any mann [q to become subject o the Wmkers'Coupon- ENERGY PEE
Z ,Z, mind Laws ofis4dlfiance.Data J•^�Sf f WATER HEATER WIVENT/ELEC R GRADING FEE
Applicant
NOTICET PLC :IL after making this Certificate of Exemption,you should WATER SYSTHM`Od7A'rING
become subject to the Workers Compensation pmvisirns of the Labor Calc,you must SOILS FEE
Wd.y forthwith comply with such provisions or this Permit shall be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ FT. Date Receipte -,
V Q kforhereby which thi that iuotwdSmctiomleading agency for the performenc<of I'
IL the work for which this permit is ixmed(Sec.709].Civ.CJ /—_
in
U Lender's Name '-✓ T(TfAL:
lenders Address TCUAL: d
�. 0. is N- B I.DIG
I anify that I have mad this application and stain that the above in6tmaorn
nF.n VJ const.i agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE S I ICFEE
U building construction,and hereby hu anize represcmmtives of this city to enter upon the all
abovcmentioned property for inspection purposes. PERMIT ISSUANCE E ECTRIC FEE /
(We)agme rat save,indemnify and keep harmless the City of Chicane.against
liabilities,judgments,costs and expenses which may many way aceme against said City ALTER OR ADD TO MECH, =MECHANICAL
_in conseuence of the granting of this permit.APPLICANT UNDERSTANDS AND WILL COMPLY WI'I'II ALL NON-POINT AIR HANDLING UNIT(TO 10,00d CPM)SOURCE REGULATIONS. AIR HANDLING UNIT(OVER 10,00)CFM)Signature ofApplicardContmctm Date EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupantstoreor handle hamNous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532m)] LIGATING UNIT(OVER I X.Mr)BTU)
CI Yaw 111M1'o VENTILATION FAN(SINGLE RESID) PAID
Will are applicant or future Fainting occupant use equipment or devices which BOILER-COMP(JHPOR 100.01M BTU) Data ReccipuX
temit usealdm is err crnnadmitaa res defined by the Bay Area Air Quality Management TOTAL.:
District? BOILER-COMP(OVER 100,000 BTU)
Dyes P4S,
I have deal the boardersrmmerials reluirements under Ch wrri.95 rf Ne Cali- AIR CONIlIT10NEN ISSUANCE DATE
forma Health&Safety Cade,Sections 8505.25577 and 255]4.1 un cesund that if Ne NEW RESIDENTIAL MECH, SQ.Fr. 9
build,.,does not currently have a tenant,that it is ru,no onsibdity o notify the occupant r [� T
of lhe«yuimrpppI which must he met prior to issuance of a Certificate of Occupancy.
Owner nth ate gem = Duce TOTAL ISSUED BY: 42
OFFICE
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
_ CITY OF CUPERTINO
• BUILDING PERMIT INVOICE OPERATOR: chriatya
Sec: Twp: Rng: Sub: Elk: Lot:35618055.00
INVOICE DATE......: 12/14/1999
REFERENCE ID # ...: 99120089
SITE ADDRESS .....: 21582 COLUMBUS AV
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA ...... .
OWNER ............: JENNINGS, JANICE
ADDRESS ..........:
CITY/STATE/ZIP ...
CONTRACTOR .......: MIRAMONTEZ, RICK LIC k 20927
COMPANY . . ........ : MIRACON CONST
ADDRESS .. ........ : 5171 RAFTON DR
CITY/STATE/ZIP ...: SAN JOSE, CA 95124
TELEPHONE . . ......: 4082642059
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- --- --------- ------------ ___________
BPERMFEE P 77.00 0.00 77.00
BSEISMICRE P 0.50 0.00 0.50
_________ ____________ ___________
77.50 0.00 77.50
V ID DESCRIPTIO:.----.... VOICE ID .------ DESCRIPTION
...... ........ .................
101 FOUNDATION 312 CHIMNEY REBAR & STRAPS
514 FINAL PUBLIC WORKS
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