00010053 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY rJdU/OOS'.3
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO
BUILDING DIVISION APPLICATION/I'FRMIT PLUMHING-MECHANICAL SOOOI
BUILDING PROJECT IDENTIFICATION'
BUILDING ADDRESS: SANITARY NO, APPLICATION$I1HM1"ITA(.UA'1'L
/-
tym
OWI, R'S NAME: PHONE: CONTRACT OR NAMEI LIC NO'.
`O NEC CON'IROLH
RCHIC/ENGINEEK LIC ADDRESS. n��// ❑
UNTACE PHONE: /�- / ��Q 6. ` BUILDING PERMIT INFO
/O ),?V l9qq ❑ Consul[tan ces�Paid y App ii(nnn (Inifial) BLDG ELF❑.C9' PLUMB ME❑CH
(LICENSED CONTRACTORS[)[:CLARA']'[ON QTY ELECTRIC PERMIT FEE
Irf�-r/
1 hereby affirm that L am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
a`SZ in Sectia andelicaf Division 3 of Basimccs and Pmraavions Code.and my license is RESIDENTIAL-
WO, with PERMI3'ISSUANC1i
C-F %� ����(��[��J ���/�� ❑SIV WI. L1 KITCHEN REh10UF:1.
QUU Licensect., ✓�—Lic.N_7 -fes APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
NZ W Date Contmcmr
I F,CI'S DECLARATION ❑
ARCHI' MULTI-UNIT El STRUCTURAL
Z O m'Z 1 coderansnnd my plashall be used a,public records PANELS MODIFICATION
O
UP TO 20(1 AMPS Z-Q [I INTERIOR ❑SWCHIMNEY
MINGPREPAIR
O
%tafVW l.iccnncA Pndcssi.nal 201-10fXIAMYS IMPROVEMENT E]SWIMMING POOLS
�.,E; OWNER BUILDER DECLARATION OVER 1000 AMPS [I BATH REMODEIJREPAIR El DEMOLITION
,=¢ 1 hereby affirm that I am usempl from the Contractors License Law for the
X3 d U following reason.(Section 7031.5,Business send Professions Code:Any city or county SIGNS ELECTRICAL C1OTHER
W Ice IFwhich requires a permit to consvoct alter,improve,demolish,or repair any.swnumOf
O primo its issuance,also requires the applicant for such permit to file a signedslamment SPECIAL Cl RCUI'I/Ml,
that he is licensed pursuant nthe provisions el'IheCbmracou's J,imo,[-a.oChamOr9
1+10C (commencing with Section 7000I.f Division 3ofine Business and Professions Cde)mr TIME METER OR YOL COMMERCIAL,
a a e K that he Is cxcmpt dandmm and the basis for the dlegcJ exmnptka.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
_, Section]031.5 byanmci
y applicant fora .it subparts the applicant avil penalty of POWER DEVICES
m' [I TENANT El[:Do[)SERVICE.nut mothan five hundred dollars
�Z6I.as owner ofthe norm laces with wages their side compensation, SWIMMING PO .E IMPROVEMENT
G ❑ property, temp Y gesas perm _
s�o wulem he w.rk.anamrere
eaemis nm mterdederr idrend hahassler, e(sec.71w4,Bamesx ❑oTtLER
and Professions Cade:The Contractors Licome Cars Js not apply 10 an owner of OUTLETS-Swl'1'CHF:S-FI RP
property who builds Ur improves demon.and who does each work hitnwlf or mrnngn
his own employees,provided Nat such improvements arc not inlendN err.Rood fur NIoV RT SIDI'NTI it ILEC'I'R S
sale.If.however,the hvildingorimpruvemore issuld within one y1olefmoplclion,the SQ.FI.FLOOR AREA 11SQ,FT.
sewn
ter-h milder will have the burden of proving ma he did not build or improve for pur-
pose of wle.).
E]1,as owner of the property, ro
am exclusively contracting with licensed moremrs 1. TOTAL:
construct me prgcct Nov.70W.Barin,,and Pn,fasioa Code:)'rbe Contractor,bi
-
oseLawdoesnolapplyu,an owner(if property whe builds or improves thereon.and QTY. PLUMBING PERMIT FEE
who contracts fur such Projects with a cer actors)licensed pursuant to the Contracmr s
Liccme Law. PERMIT ISSUANCE
1 am cxcmpt under Sec. .B&Y C fur this reason
Owner Date AI:fER-DRAIN&VENT-WATER(EA) VALUATION
WOR KERS COM Pl:NSATION DECLARATION BACK FLOW PROTECT.DEVICE /9/1
1 hereby afitm under penalty of perjury one of the following declomism, --vv VVVV
I have and or 11 maintain a Corti fiam of Consent In olf-insure far Workers Compeer- DRAINS-FLOOR,ROOF.AR EA.COND. STORIES TYPE CONSTRUCTION
lion,as provided far by Section 37N)of the Labor Code,home performance of Be
work for which this permit is issued. FIXTURES-PER TRAP
❑ I have and will maintain workers Cu nsat'no Insuoncc,as required by Section
3700 of Nu Labor Curie.for the -rfrnnta 'of the work for which this Pcrmitsiauc . GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My w.rl, tot urpne nand Policy no ///1�M GAS 4IF.A)
Carrico Policy No: / -T Y a.Y 3-S?/q J
0/t
CERTIFICATE OP EXEMPTION FROM WORKERS' � �7n
COMPF,NSA'I[ON INSURANCE GREASEINDUSTRL.WASTE LN IERCF,PfOR
BUILDING DIVISION FEES
(This section need not be completed ime pfermit is rr-one hundreddollars 11100)
f
r less) GREASE TRAP PLANCI IECK FEE
1ttmlfythatmme pedammorcc.ddeworIs forwhich thispeow ki...ed.Ishall SEWER-SANITARY-STORM EA.200 FI'.
not employ any person in any manner so as m become subject to the Workers'Cooper- ENERGY ENERGY FEE
zZ cation Laws of Califnmia.Date WATER HEATER WNF.NT/F,LECfR
Q Applicant ) GRADING M.7.
rNr NOTICE TO APPLICANT.If,after making thin Ccmficam of Exemption,you should WATER SYSTEM/TREATING
a , becrnnesuhjecl la the W.rkcrs C.na,men ea provisions of the labor Code.you roma SOILS FEE
fonnwithcomply with such pmvismns.,,his pcnnit,hall IN doomed revoked. WATER SERVICE
D
CONSTRUCTION Ltion lending
NEW RESIDENTIAL('LMH. SQ ET. PAID
U Q k or
affirmthatcoven isaamnuuc.30 lending agency tonic perinmwnce.l Ilam ReceiptM
F" the wars fur whim thin permit is issued(Sou.3P)].Civ.C.)
Lenders Name TOTAL:
U I,cndcrs Address TOTAL:
0. I certify that I have real this application and.aato that he amwe information is BUILDING FEE
coned.I agree m annply with art city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U Z building commotion,and hereby audowe reposentatises of this,city R,enter upon me SEISMIC PEE
abnveomminned PoTody for inspection purposes. PERMIT ISSUANCE(We)agree..save,indemnify and keep harmless me Ne City of CuIsmimo against ELECTRIC FEE
Iiahllities,judgmems,nnunnd expenses which may in any wiry ascot against said City ALTER OR AUDIO MECI I.
in consequence of me granting of this permit.
PLUMBINGIEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH Al.l.NON-POINT AIRHANDLINGUNI'I'(TO 10,000CFSP
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10.000 CFM( CONS]RUCL'ION'1'AX
Signature nfAPPIiaMCnntncem Date EXHAUST HOOD(W/DUC) HOUSING So 1'IGAr30N FEE
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or future building occupant store or handle hazardous mamrial II EA'1'1 NG UNIT(TO 100,000 BTU)
as defined by the Cu,smino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532m)? HEATING UNIT OVER I(X),NX)BTIJ)
pYcs [:1N0
VENTILATION PAN(SINGLE RES]DO PAID
Will the applicant.r future building t use equipment or devices which Date Receipt p
pp 6xehe Il Area
n BOILER-COME 1111P OR IW,IKK)B"rU)
mit haaareous air contaminants as JcEneJ by the 1{ay Area Air Quality Management
DOTAL:
isvieR
E]YO, Fl No HOILER-COM P(OVER 100,000 BTU)
1 have read the hazardous materials"Otimmenm under Chapter 6.95 of me Cali- AIR CONDITIONER ISSUANCE:DATE
fUmia Ifealtb&Stdny Code,Sectio ns 25505,21,533 antl 25534.1 undecsm id that if me NEW RESIDENTIAL SUCH. SQ.IT.
building secs not correctly have a meant that it is my re poaibilo,to n.dfy the or'cupanl
of the w,mmmmn's which moa he met no m Lswanice of a COmr.,me of Occupancy.
Owner ser authorized agent Date TOTAL: ISSUED BY:
OFFICE
1TRN.10.2000 10:47AM NETCLERK INC 00.1397 P.26 _
CITY OF CUPERTINO
BUILDING PERMIT APPLICATION
F LT 10300 Terre Ave. Cupara1110,Ca.M14
(408)777.3229
PROJECT ADDRESS:7603 ELDERWOov cT
SLOG#" SUITEJAPT t�
PROPERTY OWNER CONTRACTOR
OWNERS NAMd MELINAUSKAa.A
NAME helWater
inC.�0 0015211
MAILING ADDRESaT ELDEmN00D Cr MAILING ADD
RE98: )Owwlend a s
aTYATTATElZIP: CUPERT)NO G 06014 CR1g87ATE?)P•
PNONEA:( 4 0 0)257 8633 FAX#: ( Mn qrCA "0i0
PHONEdk( e60)206�8404 FAX$ ( e6¢?9egd03
ErwL ADDRESa:
WMAILAOOR>SE:�+b •wm
3 0/6— "INESSLICE"MAt 21311
M'LAIN WORK To 8E PFRFORNW: REPLACE WATER NEATER
1A1PtCA1 PLrn mIN&. of
1040pi AAZ&R=W MR AVSD Tab xD� NWOM OFinangg1 ROOF Co
TYFB OF E7C5=0Roov covEaDjo. "�'��
FROPOSBDBDOFCOV11 NG.,
►�7DlOFIDUSTIIW3B00FCOv8RIN05 il10tOVgD: 0
NUN=OF&%=Di0 ROOF COVEMO8 UTADW: 0
PROvma LO.a.O.RBFOAT NO.
• IMPORTANT NOTICES NOTICE TO APPLICANT
APPLICANTa C11"FICATM I h"*'"'"n umw"nft of"fv ere d the f smAng dsdamffors;
I CERTIPI'THAT 1 HAVE READ THIS APPLICATION AND STATE THAT THE 1 ) t 1 Nue elal r41 nWnlsln s oudlhb wtepntenf m W f�retpa far veheq'eawr.
W FOR THE DEMOLITION p g�AEp SETHIS APPj THAT IF A PERMIT 18 M
UGTION ALL THE / Pawtbn.a PraWdWP�00 37
PROVISIONS OFyJ of1h..oricvw dt ea. °f eb Lobar Cdda,ra tlr prfo„n.,,o,
THE PERMIT wrr ALL LAWS AND ORo1NANCa6
THERTO WILL S8 COMPLIED WTTF). 1 aUon w ow um **for eenpwnweew hwtrrsnwe,as ngWred br,sap
HOLD
s)AMLE99 OLAUBE.Thr Penhhr(s)by seeaptermp of too pwnnR urea Wold. Ny kin�OwroadM Y&Wlfporkmmillas lw evrbrendh*icy ich n m
to Cllr era hold hermlen db as d eupenhw%m era ber v sbeb fund
11911M do and eo dolma,dernmrde and achene for darn&M f4@wL p Sem
"own. dt psum d'aParra7OQirdleesarool¢enoldmeergaeul+elaw wmbd 1S48WO
deft.demwrds or galore. t ) a The
allot dae rah darbila0 aloan
U mMonnhr rAlh wodN MeersleM of w cdonhave 3800 d tlts Lsbar Cede� < ) N wady awn*0 Npdhmy:v daewdk fa rNdr ar.
8ts4 d CWlbmb.Ne Wplimntat411 have c . YrdtN(Q, I dee
hilsd bslnw orshep lrtdfobibme 010,or Pa)' r Penan In nb msnnn9e Pomrlabavad'I
e hwrgvsr Ilam(V)le chewbd ibm fM•ar Whiehsrwr Is *Viebb, w'o" ween beo d a•b beam Tr to WD&
(M must a albcksd r rwLL Msh Pm awl�dw a+em au I ahm�b**am l wbj d a4mmMedas Mur i bldarow'd
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lowlelW afte Labor Coded Cwnfam",V ha m aw,ift mra.wn ft
LICeuaF0 e0NTRACTM DECLR&ndm Ae p110" „� p fttabes oode�her a,a mm
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Lk""W.783612 to r Nbwldb w.mde a novae,I c"ItrwP1�ay,e am aom see
Gawe`—tlb DS131R001 nwwmwm d rworlaft,amwtwaa Aen Isvr of CaNrwngo&V vow. to Me ca r
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PAYMENT
ACCOUNT*
CREDIT CARD TYPe ARATION 1)
NAME ON GRD: Q
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