00010051 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
C_ TTY OF CUPERTINO BUILDING-ELECTRICAL PERMITN
BUILIi1NG DrvIS1oN APPLICATION/PERMI'1' PLUMBING-MECHANICAL 50001
BUILDING PROJECT HIFNTIF'ICATION
BUILDING ADDRESS'. boob D"- %ANITARY NO. APPLICATION SUI{MITTAL"I
OWNS 'NAME: 1/ IZ: CONTRACTOR'S NAME: �7I�C LIC NO: NIC CONTROLa
.4 eJA
CIIITECf/IZNGINEER: 'LIC NO: AD RBS : ❑
CONTACT PHONE: c/ i BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant aided) BLDG ELECT PLUMB - MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
e Iz z I hereby affrr Nut 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
with Section7")of Division 3 of Ne Business and Professions Code.and my licenw is RESIDENTIAL,
{y O O PERMIT ISSUANCE
FI— in full innermost effect. ❑SFE)WI. ❑KITCHEN REMODEL
�U�j License Class Lic.p
F+� Date Contramor APPLIANCES-RESIDENTIAI. ❑ADDITION ❑PLUMBING RE-PIPE.
¢1
FN.Dy ARCHITECTS DECLARATION PANELS []MULTI-UNIT []STRUCTURAL
Z O MZ 1 understand my piens shall he used us public records MODIFICATION
OZ—� UPT02MAMPS ❑INTERIOR (-I CHIMNEY REPAIR
t-g,jW Licensed Pmfessioial 201-1000AMPS IMPROVEMENT SWIMMING POOLS
bg,9.� OWNER-BUILDER DECLARATION OVER IWOAMPS ❑BATH REMODEL/REPAIR El DEMOLITION
C s�'6 I hereby affirm Ihm I am exempt Pram the Contractor's License Law Iia the
{iyS O y U following reason.(Section 7031.5.Business and professions Gyle:Any city or county SIGNS ELECTRICAL D OFFER
su :Y.y which requires a permit m construct,alter,improve,demolish.or repair any swcture
F�0 prior to its issuance,also accounts the applicant far such Permit o file a signed statement SPECIAL CIRCUIT/MISC.
} previsions that he is licensed pursuant to the pvisions of Commences Commces License Law(Chapter 9
a0 (commencing with Section 7001 of Division J ofthe Business and professions Code)or TEMP.METER OR POLE INST.
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
aG I+N. Scat n]OJ LS by any applicant furapcnnit suhjeds the applicant toacivil q:noRy of POWER DEVICES ❑TENANT ❑FOODSIiRVICE
Yl t ntthan five hundred 11.($500). IMPROVEMENT
SSC as rrwner of the pmpeny,or my employees with wagesma theirmlee mperomme, SWIMMING POOL ELECTRIC
yF willdo the work,and the nrunure is not imm�ded oroWrtdfnrmle(Sec.]044,Nuxincss ❑OTHER
LLl and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
pmlwrry wha builds or improves thereon,sad who does such work himself or through ,
his own employees,provided that such improvements are no,intended or oficas!for NEW RESIDENTIAL F.LECTR S
sale.If.Inwesec,the building or improvement is sold within one year ofmmpletion,'he 'SQl'R\FLOORAREA 1 $/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for par-
pose of ante.).
I]1,us owner of rhe property,am exclusively contracting with licensed contractors to N 112000
construct the project(Sea](H4,Business and Professions Calc:)The Courteous Li-
cenceLawdoesnetapplytomrowner(if property who builds or improves thereon.and QTY. PLUMBING PERMIT E
who contracts for such projects wird a contractors)licensed pursuant to the Contractors
❑
License law.tem PERMIT ISSUANCE
exc pt under Sec. .B&P C for this mason s
ALTER-DRAIN&VENT-WATER ITA) aN
r - Dam
WORKER'S COMPENSATION DECLARATION HACK FLOW PROTECT.DEVICE 7 N
1 hereby dorm under penalty of perjury one of Ne bolowing Jeclarminm: �J
I have and will maintain a Certificate of Conant to self-inmnt fmrwmker's Compen- DRAINS-FLOOR.ROOF,AREA.COND. STORIES TYPE CONSTRUCIOD
satin.,as Prided for by Section 3700 of the Labor Code,for the pafmmnnce of the
work for which this vomit is issued. TEXTURES-PER TRAP
❑ I have and will maintain Worker's Compensation Insurance,as required by Section
37011 of the Labor Code,far the performance nl the work for which this permit is issued. GAS-EA.SYS]IN-I INCA OUTLETS OCC GROUP APN
My Worker's Compensation Insurance carrier and Policy number are: 2/ t✓O O
Cartier. Policy No: GAS-EA.SYSTEM-OVER 4(EA) O O
.36
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE/INDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE I BUILDING DIVISION FEES
(This section need not be completed ilthe Permit is Forane hundreddollars(SHE) GREASE TRAP
or[c,,.) PLANCHECK FEE
I crony that in the performance of the work for which this pe.I,is issued,Is hall SEWER-SANITARY-STORM HA:200 FT.
not employ any Person in any manner so as m become subject 1.the Work.-Co.,.- ENERGY FEE
z s arm Laws of C.Iifiw iu.Date WATER BEATER W/VENI E-LECfR
77�O Applicant I GRADING FEE
NOTICE TO APPLICANT.If,after making this Certificnte of Exemption,you should WATER SYS'I HMITREATING
became mhjea to the Workers Compensation pavilions of the Labor Code,you must SOILS FEE
Wforthwith comply with such provismatmthis pemit shullh Jcemed revoked. WATER SERVICE.
Q
CONSTRUCTION E.ENDINGAGENCY NEW RESIDENTIAL PLMR. SQ,FT. PAID
z Dae Receipt
GO If whihhi th emere ixsued(Sre.30lending agency for performance of
(~ the wad for which his permit is issued(See.3114],Civ.CJ
� Lenders Name TOTAL:
U Lender's Address TOTAL:
1311 certify Nm I have read Be,application toad sate that the above information is BUILDING ITS
f0.A cortmr.l agree to comply with i lI city and county adiao.cea arta state laws minting m QTY. MECHANICAL PERMIT FEE
U Z building construction,andherebyauNmire representatives ofthis city meaterupon the SEISMIC FEE
shove-memiomed pm,wr y for inspection p.,wrs. PERMIT ISSUANCE
(We)agree to owe.Indemnify and kw p harmless the Calof Cupertino against ELECTRIC PEE
Iiabilitics.judgments.costs and expenses which may in any way accrue against said City ATTER OR ADD TO MECH,
PLUMBING FEE
in consequence of the gmming of this permit.
APPLICANT UNDERSTANDS AND WILL 90MY WITH ALL NON-POINT AIR HANDLING UNIT TO 10,000 CFM)
MECHANICAL FEE
SOU EGULATIONS.
MI MISHANDLING UNIT(OVE.R 10,000CFM) CONSTRUCTION TAX
Si mmeof ApplicanUCnntmctor Ute EXHAUST HOOD(WMUCq) HOUSING MITIGATION ITE
HAF.ARD A S MATERIAE S DISCLOSURE
WilUheapplicsmmor fmure building cecupam store mleadle hazardous material HEATWG UNIT(TO 100,00111 BTU)
os defined by the Coliseum Municipal Care,Chapter 9.12,and the Health and Safety
Coda,Section 25532m)p\ HEAPING UNIT(OVER 110,"BTU)
❑Yes No VENTILATION PAN(SINGLE RESID) PAID
Dam RcceiptN
Will the applicant m future building occupant use equipment or devices which BOILER-COME'(3HP OR 100,000 BTU)
Iran District? s air comami ants as defined by the Bay Area Air Quality Management TOTAL:
District^
❑Yes No HOILER-COME'(OVER 100.000 BTU) _
�
I have read the hazardous mateduN re,nnnown¢under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE DATE
foods Health&Safety Cal,.Sections 25505.25533 and 25534.1 understand that if Ne NEW RESIDENTIAL MECH. SQ.FT.
builNn6 « nm<ummly haveatenan that it ix my respamibilitymnaify Ne cecupam
of Ne irements which must be me oI. Certificate of vpa
Owner or outhc ed agent ( TOTAL: ISSUED BY
OFFICE
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
. BUILDING PERMIT INVOICE OPERATOR: nancyc
Sec: Twp: Rng: Sub: Blk: Lot:32650030.00
INVOICE DATE...... : 01/11/2000
REFERENCE ID # ...: 00010051
SITE ADDRESS ..... : 22272 CUPERTINO RD
SUBDIVISION ...... .
CITY . ........... . : CUPERTINO
IMPACT AREA ..... . .
OWNER ........... . : KLEIN BERNARD AND PAULA P TRUS
ADDRESS .......... :
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-5140
CONTRACTOR ....... : LIC # -OWNER-
COMPANY ......... . : KLEIN BERNARD AND PAULA P THUS
ADDRESS ......... . : i
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-5140
TELEPHONE ....... , :
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
V ID __._.. DESCRIPTION ---.---. VOICE IO _ DESCRIPTION
301 ROUGH PLUMBING 303 ROUGH MECHANICAL
304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL
507 FINAL PLUMBING 508 FINAL MECHANICAL
•