00010157 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUII,DING.ELECTRICAL PERMIT NO.
BUILDINGDIVISION APPLICATIOWPERMIT PLUMBING-MECHANICALlow
.r BUIL.DINGPROJf:CTII)ENTIFICATIONt '
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
Ainki"AEg' NA 1'HONF:- 3L30CONTRAH'S NAli: kAs On/ LIC NO. NIC CONTROL
ARCH/ ':f/ENGINEER: LIC NO. DRESS: ❑
L4 ;Oa4
CONTAC'E PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC- LCECTRIC PERMIT PEE •
p 1 heream affirm that l m I' n d oder pr s f Chapter 9(anmmehelhg t _ JOB DESCRIPTION
wo,-, wthSecti�n WllNllnf❑' n 9 yf the Buniesanl prfesson,C Banduty beer.is RESIDENTIAL:
FWZ efull Bacauuleffecr /_ PERMII ISSUANCE ❑SFDWL O KITCHEN REMODEL
aUU License CF s V Lm I PPLIANCCS-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
t Q 6ix, Dam 'S DEmr
ARCf11TT:CTS DECLARATION [I MULTI-UNIT ❑STRUCTURAL
ZpyZ I understand my plans shall he used as public tee PANELS MODIFICATION
pZ-O UPT0200AMPS ❑INTERIOR [I CHIMNEY REPAIR
P:41"JM Licensed Professional - 201-1000 AMPS IMPROVEMENT [DSWIMMING FOOTS
;5Y2; OWNER-BUILDER DECLARATION
C Q I hereby affirm that 1 am exempt from the Contractors License Law for the OVER 100(IAMPS ❑RATE REMODEL REPAIR ❑DEMOLITION
o:a tU- following reuun.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
LL which requires u Perms to commuct,vlmr,improve,demolish,or repair any structure
L-'ftn.0 prior wit,isnuance.tim copirestneapplivent for such Perrino Ele ani,pmdstatmnmI SPECIAL CIRCUIT/MISC.
WQ� ohm he is linseed pursuant m tea'amli,mmifthe Comon,im's License Luw(Chaprer9
WFS O (commencing with Section 9010)oTDivlsion 3 ofthe Business end Professions Code)or 'I'EMIR METER OR POLE INST. COMMERCIAL:
d 2 qe that he is exempt therefrom and the basis for bandaged exemption.Any violation of ❑NEW RLDGIADDITION []DEMOLITION
�r Section]031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑ ❑
u1-m TENANT FOODSERVICE
not mare than Eve hundred dollars(SSIXp.Z Y IMPROVEMENT
C ❑Las he work,the the
intended
tendwifhwagesastnei( ate compensation, SWIMMING I'00L ELECTRIC
will do the work,and the he Com is not s skins or useedJ for sola(Say.])no Boniness []OTHER
Land property
who
CoJo',The G es Ilacreon License w Lawdoess such
not apply s un owner of OUTLETS-SWI'fGHES-PIXTI11f1iS
property who builds or improves she such
i and who docs such work himself nr nhough
his own nnployees.pnrvidW than such impmvemcnts are sol intended in oRcrui for NEW RESIUIiNt'IAL ELECTR Ff
sale.If.however.the building or improvement is sold within oneyeantfconpletiymthe SQ.FT.FLUOR AREA ESQ.rE
er-builder will have he bodes of proving cleat he did nor bui1J or impmva for pin
{nim ofsale).
❑ 1,as owner of the property,um exclusively conducting with licensed tmdacrers m TOTAL:
nnndacr the prnjot Sec.7(D4,Bnvinesn and Professions Code:)Thy Cnmmetyrs Li- r:- - -
nseLawdoesnotapplytoanownerofpropertywhobuildsorimprovesincome,and QTY. I PLUMBING PERMIT i i FEE,., ,
who sermons far such propos with u emmiactuds)licensed lommenuo the Connector's /
femme Law.
PERMIT ISSUANCE
FlI am exempt under Sec. .B&P C for this reason
Owin, Date ALTER-DRAIN&VENT-WATILR(EA) VALUATION
WORKER'SCOMPENSATION DECLARATION BACK PLOW I'IIOI'IiCT.DEVICE �/•1�N OCA
1 ninety Al mai under penally of Perjury one of the following Wm1mr`Cm f...,��lJ
❑Ihave and will maintain aCmet 37 mof The Ladnu Codrnfor. The Workdsce of the
DRAINS-FLOOR.ROOF,ARL'A,COND.
STORIES TYPE CONSTRUCTION
emacs,as which
this
rot by Section 3]n0 of The Labor CrtJe,for The performance of the
wn�forwhich this onarris iaucd. FIXTURES-PER'IRAP
i have't�m�/J�/w�y"i'll mainuin Wnfrk�le�rS's��Compensation Insuran�cee,as required by Section
37010aCMy amW�frk ' 'Cade,for tl .urbtyd—Polly Noyfn/ Mall suW. GAS-EA.SYSTEM-ZINC.4(EA) iTS
he OCG GROUP APN
GAS-EA.SYSTEM-OVER 4(EA) (�
CERA ICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE I GREASMNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION IL'FS
(Thissenion am .becnmPlerW ifNe permit is f hundred dollars(5100) OR
or '
or las., PLANCHECK FEF.
lurtify that in theperfnrnutncardiac work lnr whiclide,, rn...is landed,lnhallSPWPR-SANITARY-¢'FORM f?A.200 FT.
not employ any person in any manner so as to hacome subject to the Workers'Compen- ENERGY FEE
0 Z coach Laws If Culifnmio Dam / WATER HENDE-RW/VTNTOELECTR
z Applicata GRADING FEE
y NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/IREATING a 5011 4 FEE become subject to the Workers ComPcnsation provisions of the Labor Code,you must
Wbnhwith comply with such provisions or this permit shill he deemed revoked WATER SERVICE
Q PAID
7z CONS TRUC I'ION LENDING
ngAGENCY
agency
NEW RE5IDI!NI'IALPLMB. SQ.FT, Date Rxei,I#
V p Ihorwhichaffirm rhanherc iso ed Xcxti0n lending agency fonhe perB+mtance of
D: U Tae dark for worn this permit is issued fsw.309],civ.C.)
O U Lender's Name TOTAL:
IxndetAha If t TOTAL:
I
ly cenil'y than I have read this application and soca that he above inlnrmmion is i _ s.. � - - PUIf,DING FEB
s•. y msmer.l agmehtutmply with nlluhy nnJcounoy nnllnantes ataslam lows reladngm QTy.. MECHANICAL PERMIT' FEE•
U Z building ctm,,met o,and Imechysemorim representa1 awes afthis city ro enter upon the t 1 r SEISMIC FEE
abuse-mentioned phr,ey far inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep hatmlesx the City of Cupertino against ELECTRIC FEE
Imbilmes,jedgments,costs it espenses which may in any wayaccmavgeinst said City ALTER OR ADD TO MECH.
in con in'
oflhe raringof this Prment. PLUMBING HEAPPLICANT 1 D STANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 111.0111 CFM)
SOURCE Rf 1 ON MECHANICAL FEE
{ �1 /+�8 •DO AIR HANDLING UNIT(OVER 111,000 CFM) CONSTRUCTION TAX
SignawmofAp t mrvnor Date EXHAUSI'H(lOD(N'/DUCO
ARW US MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will nhr. plicate orfmure building occupant store or handle nuallous material HEATING UNIT(TO II0,000B'I'LD .
Code,ntby the Cupertino Munlalpu4Code,Chapter 9,12,and the Heahh and Safety
Section
as refined HEATING UNIT(OVER I W,0011 BTU)
Ion 25532[x)?
C3 Yes ,KNo VENTILATION PAN(SINGLE RESID) PAID --
Dam Receipt X
Will the applicant i future building by
B use equipment or devices which
mit M1aaarJous sir contaminants Its Jelined by the Ray Area Air Quality Management BOILER-COMP(3HP OR 100.1100 O1V)
District? � TOTAL. �.
Ven BOILER-COMP(OVER IW,gNI II'TO,
1 have real the haysrdous realmals requiremma under Chapter 6.95 of the Cali- AIR CONDITIONER - ISSUANCE DATI?
(aria Heahh& 'af ty Code.Soriano 25505.25533 and 8534.1 undemunJ that if Ne NF.W RESIDIiNT1A1,MECH. SQ.FT. �
building d« c nllyhuautmvnt,that io is my responsibility to notify the oacuPanl Z G�
of the requis hichm met prior to iuoanceofa CertiBeafe of Occupancy.
Desecrated,t du nlc TOTAL: ISSUEU BY:
OFFICE
INVOICE INVOIC11 INVOICE , INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
J
CITY OF CUPERTINO
• BUILDING PERMIT INVOICE OPERATOR: chriatya
Sec: Twp: Rng: Sub: Blk: Lot:32641001.00
INVOICE DATE...... : 01/28/2000
REFERENCE TO # ... : 00010156
SITE ADDRESS .....: 10417 ANSON AV
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA . ......
OWNER ........... .: AMERICAN HOME SHIEL
ADDRESS ....... ... :
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-1304
CONTRACTOR .. . ....: MCGEE, PAT LIC # 18986
COMPANY WATER HEATERS ONLY
ADDRESS .......... : 500 AIRPORT BLV
CITY/STATE/ZIP ... : BURLINGAME, CA 94010
TELEPHONE ........ : (415)349-3747
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- --- --------- ------------ -----------
BPWHEATER P 9.99 0.00 9.99
PPERMITFEE P 35.52 0.00 35.52
--------- ------------ -----------
45.51 0.00 45.51
OfDESCRIPTIO-_--.-...- VOICE ID ...-----DESCRIPTION
....... ........ ............
106 SEWER fi WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 302 TUB fi OR SHOWER
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING