99110156 APPLILICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY (:7q 110/ S-40
CITT OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILODING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL gx00o1
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRISS. SANITARY NO. APP ITAL DA'
�N�A�M% PHONE: CO C' NA LIC NO:
n� #
N/C CONTROL
RCHITECWENGINEER: LIC NO: :SS: ❑
CONTACT. PHONE: CD
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) DG LLECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hueby m(finn that am licensed under provisions of CM1upter,9(commend"g J08 DESCRIPTION
Z 'NSeefion'IB�B�LE{$yfffy�DDDDry/y c/3y fthe Busine Professions Codo;mdmylicense is RESIDENTIAL•
F 47 n full force ens-/— PERMIT ISSUANCE
F-zUU License s Lie. ❑SFDWU ❑KITCHEN REMODEL
N61 Date un Curatao% APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING
URALRE-PIPE
0aiz ARCHITECTSD NELS ❑MULTI-UNIT ❑STRUCTURAL
OZ`~Z d rand my plans shall noticed as public record ib0�� IFICATION
�V UP T0200 AMPS __ ❑INTERIOR CHIMNEY REPAIR
_F�.F.,W licensed Professional 201-IWOAMPS IMPROVEMENT 0SWIMMING POOLS
Y OWNER-BUILDER DECLARATION OVER IOW AMPS ED REMODEL/REPAI ❑DEMOLITION
C I hereby affirm that I am exempt form the Contractor's License Law for the
O U following reason.(Section 7031.5,Business and Professions Code:Any city or county ❑OTHER
a W
F. which as a t to cnnswd,alter,int SIGNS ELECTRICAL
F,O ha oequir Lerma prove,demolish,or repair any struaure
gym.i prior to its issuance,also requires the applicant for such permit o file a.signed dominent SPECIAL CIRCUIT/MISC.
9ggqWW That he is licensed pursuant to the previsions oftbo Contractors License Law(Chapter 9
W—M0 (commencing with Section 7000)of Division 3 oftbe Business and Professions Code)a, TEMP.METER OR POLE INST. COMMERCIAL
a y m a
That he is exempt,thereGom and the basis for the alleged exemption.Any cadmium of ❑NF,W BLDG/ADDITION C1 DEMOLITION
4X7 t°• Section 9031.5 by any applicant for a permit subjects the applicant m a civil penally of POWER DEVICES
F y y not mare than five hundred dollars($5W).
UTE ❑FOOU SERVICE
WBL
6 ❑I,as owner of the property.or my cmployeeswilh wages as their sole campensetiou, SWIMMING POOL ELECTRIC IMPROVEMENT
IS..� will do the wool,and'he maintain,is no,amended oroRered for sale(Sec.]IUW,Business ❑OTHER
3 and Professions Cade:The Carntadors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
progeny who builds or improves thereon,and who does.such work himself or through
his own employees,provided that such improvements are oot intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If,however,the building or improvement is sold within one year ofcompletion,the SQ.FT.I7LOOR AREA $/SQ 14.
insmor-hailder will have the burden of proving that he did not build lir improve Letitia,
pose of atia).
❑1,as owner of the progeny,am exclusively contracting with licensed convectors to TOTAL:
construct the project(Sec.9040.Business and Professions Code:)The Contractor's Li-
nse taw does not apply to an owner of Property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such Foments with a exammetor(s)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
❑ 1 am exempt under Sec. ,B&P C for this reason
r ALTER-DRAIN&VENT-WATER(EA)
Dam VALUATION
rte WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE �J
1 hereby a/tirm under penalty of pe jury one of the following declarations: LY/
❑Iheve and will maintain Certificate of Cnnsenuoself-insure ria Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. STO IES TYPE CONS]RUCTION
emina provided far by Section 3900 of the Labor Code,for the performance of the
war or hichilhospennit is issued. FIXTURES-PER TRAP
e and will maintain Workers Compensation Insurance,as required by Section
Wofthe Labor Code,for the lice !the work for which this permitJJee"++�Isued. GAS-EA.SYSTEM-1 INC.4 OUTLETS
My Wor��-/r/1 �Ii�Ly�yyyrsww��ff��qq��yy//��{{�' and Policy�j:_J OCC.GROUP PIsL
CarrioM1�v� LLPolicy Ism • GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OP EXEMPTION FROM WORKERS' O�
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
(This section need not ba completed if me permit is futon hundred dollars($1 W) BUILDING DIVISION FEES .
of less.) GREASETRAP - PLANCHECK FEE
I certify that in the performance of the work for which this pit is issued,l shall
not employ any Person in any mannerso as to become subject to the WorkersCompen- SEWER-SANITARY-STORM EA.200 FT.
z ENERGY FEE
s
z O Applicant t cion Laws of California.Date WATER IIFA'tE0.W/VENT/ELECTR GRADING FEE
y NOTICE TO APPLICANT:If,after making this Comficam of Exemption,yon should WATER SYSTEMl1'ftEATING
h become subject m the Worker's Compensation provisions of the Labor CNe,you must SOILS FEE
W A forthwith comply wimaoh provisions or this pemtitshall be deemed becolved. WATER SERVICE
a
CONSTRUCTION LENDINGAG NCYagency NEW RESIDENTIAL TIME. SQ.FT. PAID
V work
by whahthisprhat there isacd(Sit.3097,leading agency for the performance of Date Receipt
LTr � me wook Por which this permit is issued[Sec.3091,Civ.CJ
Lender's Name
Lenders Address TOTAL: TOTAL
LL I certify that I have read this application and state that the above information is BUILDING FEE
i-r fA cored.)agree to comply with all city end county oNinanecs and state laws relating to QTY MECHANICAL PERMIT FEE
V z building construction,and hereby authorize representatives of this city to enter upon the SEISMIC PEE,
above-mentioned poiieny fur inspection perposes.
(We)agree m'save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liabilities.judgments,costs and expenses which may in any way accrue against said City AIITERORADDTOMECH.
in corse lienee oftne an his
permit. PLUMBING FEE
AT .T ON ;RS' D AND WILL COMPLY WITH LL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
U R TIOIS. MECHANICAL 17EE
"�� AIR HANDLING UNIT(OVER IO.aW CFM) CONSTRUCTION TAX
Signature mfA,,ficmdA:onfAtmr Data EXHAUST HOOD(W/IIUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applican a,turn.building tarpon smreor handle hamukre,material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? HEATING UNIT(OVER 100,000 BTU)
❑Yes
VENTILATION PAN(S INGLE RESID) PAID
Will the applicant a future building occupant use equipment or devices which Date fteucipt# sJo
emit hmardous air conmm marts as defined by the Bay Arca Air Quality Management BOILER-COMP(3HP OR 100,OW BTU)
District? 'DOTAL'
-]Yes BOILER-COMP(OVER IOO,WII BTU)
I have read the hm ors matedale AIR CONDITIONER ISSUANCEtpATE
myuirements under CM1apmr 6.95 of the Cali-
ITh&Safety C .Secdons 25505,2553]and 25534.1 an ersmnd nth if tAe NEW RESIDENTIAL SUCH. SQ.IT. ll
filing not moll a mnant that It is my responsibility t arifythe comet ��— 'J
q whir met Pitot once of af,crfil uf�:
Owner orouNr edat I/ 'Date TOTAL: ISSUED BY:
OFFICE
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
BUILDING PERMIT INVOICE OPERATOR: chriatya
Sec: Twp: Rng: Sub: Elk: Lat:35618033.00
INVOICE DATE......: 11/23/1999
REFERENCE ID # ...: 99110156
SITE ADDRESS ..... : 21641 COLUMBUS AV
SUBDIVISION .......
CITY ............. : CUPERTINO
IMPACT AREA ...... .
I
OWNER ............: DOZIER
ADDRESS ..........:
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-4710
CONTRACTOR .. .....: GENE, BOB LIC # 20766
COMPANY ..........: BOB GERE MASONRY
ADDRESS ..........: 480 CROSSLEES DR
CITY/STATE/ZIP ...: SAN JOSE, CA 95111
TELEPHONE ........: (408)972-1285
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
ID DESCRIPTION VOICE ID DESCRIPTION
... .......... ............... ........ ............................
101 FOUNDATION 312 CHIMNEY REBAR 4 STRAPS `
514 FINAL PUBLIC WORKS