00010001 oo
- ' APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY d
CITYOI'CUPERTINO BUILDING.ELECTRICAL. _ PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT
t PLUMBING-MECHAALAftw11 BUILDING PROJECYIDE9C,'PION
BUILDI GADDRESS: t SANITARY NO. APPLICATION SUBMITTALDATI
OWNERS M : ` P l E: CONTRACTORS NA / LIC NO:
NIC CONTROL p
HI ECTIENGI-EF.R: LIC NO'. ISS: s ❑
u y
CONTACT. PHONE: , BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) �_ m.uG EI.ECI .PLUMB hfEcx
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
QTY p1,liC1'RIC PERMIT FEE
I hereby anion than I am licensed ander prowsioas of Chalon,9 B'omatencing .. JOB DESCRIPTION
Z
W with Sinn] )of 0ivisinn3ofthe Business vnJ ProfessinnsCode,and mylicense is PERMIT ISSUANCE RESIDENTIAL
O se= mIXM)
in full farce-and effect. ❑
- >/ SFDWI, [IEN KITCHREMODEL
a
F. UU Licenser Clns hiu.N APPLIANCES-RESIDENTIAL. ❑ADDITION El I'I,UMBING RIS PIPE
NQLData C.Goor -
ni 9�Z000ICHTTECTS DIiCLA�ON PANELS MODIF❑MUhThUNIT ❑STRUCTURAL
F n'Z , I unJetst—so n y plans shall he used as public mcnrds CHIMNEY
REP
TION
QZ—q UI'T02W AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F'f3
fLicensed Professi...I 281-10(If1AMPS IMPROVEMENT L]SWIMMING POOLS
G ]� OWNER.BUILUUR DECLARATION OVER I000AMPS ElBATH REMODEUREPAIR.❑DEMOLITION
C IY W Q I.hereby affirm that 1 um exempt It,,.,,the Commctar's License Law for the
N� following rcann(Section N3L5.Business and Professions Cele:Any city nrennmY SIGNS ELECTRICAL ❑OTHER
W 3 U.y which requires a permit to consumer,alter,improve,demolish,or repair any ewcturn
Hprior.....:stunner,also requires the applicant forsuch Parant oflea signed statement SPECIAL CIRCUIT/MISC.
SSSSQHol //
� that he in licensed pumuonnntha provisions of the Conwctor'x License Law fCbupter9 O�r—�/
AGO fcommcncin,with section?ma)nf Divislnn Sof the Basin,,,and Prafest v,Gale)a, 'TEMP.M U'I'ER OR'POLE INS'1'. COMMERCIAL
6 ty o N that he is exempt therefrom and the basis Inr the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�h Seen..7031.5 by anyapplicant farpermit aubjems the applicant..a civil penalty of POWER DEVICES (]TENANT ❑FOOD SERVICE
F.Z}• not mnrethen Eve hundred dollars($50% IMPROVEMENT
pO ❑ I,as owner of the pmpeny,lir my cmPlnyws with wages ns their sole cmnpcnsatinn, SWIMMING POOL ELECTRIC
will du the work,and the structure is not hnendni oroffemJ Gnxule(Sce.](W4,Business ❑OTHER
I
IIand Professions Cook:'fha Ccmauw u' Licame Law does not upply to Int matter of OUTLETS,_SWI'T'CHES-PIX'fURES
6 3 property who builds sir improves thereon, oil who does such work himself or through
his own employees,pmviJN that such impmssocan s are not intended o,altered for NEW R[SIIIIiNT1AL ELECTR Pf.
safe.If.however,Me building or Informant o wsd within nu
neycafcampletion,the SQ.FT.FLOOR AREA S/SQ.PI'.
cr-huilder will have the bureau of prolan,that he did nm build or improve for pur-
poseafsnle.).
I,vs owner of the pmpeny,am exclusively contraaing with licensed contractors to
construct the project(Sec.7014,Business and Professions Coh n)'Ihe Contractor's Li- - -
se Law does not apply to an owner of properly who builds or improves thereon,and QTY. PLUMBING PERMIT
who contracts for such projects with a caricaturist licensed pursuant to the Communes
License Law. PERMIT ISSUANCE
❑ I an vsarrml under Sec. ,11&P C for thi",...a
ALTER-DRAIN&VENT-WATER IIIA) VALUATION
caner Date
WORKIiN'S COMPENSATION DECLARATION BACK FLOW PROT[Cf.DEVICE
1 hereby M.under Noody of perjury one of the following declarations:
I have unit will maintain u Cenificate of Consent to self-insure far Wmkcr's Compen- DRAINS-PLOOR.ROOF AREA,GOND. STORIES t TYPE CONSTRUCTION
amino,us pmvlJed Inr M1y Scetion 3]1X1 nl Ibo Labor Code,for the performance of the
work lin which this permit is issued. FI%TURES-P13R'fRAP
I have and will maintain Worker's Compou smion Insurance,as required by Section
3700ofthe Labor Cade-,for the pe onnonccafthe work for whichd s pcmti,is issued. GAS-EA.SYSTI;M-I INC.4 OUTLETS OCC.GROUT' PN
My Worker, :ai In cecamer and Poli -7 l)7 _
t Canicc Policy Nn.: GAS-EA.SYSTI:M-OVER41EA1 ✓
CERI'II+KATEOFSEMITf"�vRPR(k,M�I ,Rt7 O GREAMIANDUSTHL WASTE INTERCEPTOR
Cf1MPENSATION'11CSlMANCLs BUILDING DIVISION FINKS
(This section need not be completed lfthe permit is fin-smchuodred dollars($100) GREASETRAP
. or less 7 PLANCIIECK FEE
I cenifythat intheperfonnanceofthe work forwhicM1thisperrom Mooned,l shall SEWER-SAN H'ARy-STORM EA.2001 FT.
real employ any person in any manner,so its m become subject at the Workers'Compel). ENERGY FEE
'z Ioban Laws of Cclifmnh.Dare WATERT HATER W/VENT/17LECPR
Q Applicant ) GRADING FEF.
NOTICE TO APPLICANT:IL after making this Cerlificate of Exemption,you should WATER SYSTEMOREATING
F ? become subject..the Wader's Compensation provisionsof the Labe Code,you must SOILS FEE
fbnhwiar comply with such provisions or this permit shall be shamed revoked, WATER SERVICE ' _
1 Q
CONSTRUCTIONLENDINGAGENCY NEW RESIDIINTIAI,PLMB. SQ.FI'. P ID's
V ya gagency pe Dare Receipt p'-•••...,y
I hereby flint Net there is aconswction lendin for the dannvnce of it s
I Its t. the work far which this permit is issued(Sao.301 Cie C.) (Lot `a UOTALi ,f
I--' Lender's Name
Lender's Address TOTAL: .
1 candy that 1 have rand this application and state that the ahove infomn tion is B ILD �) �l1
tt, y correct.higme to comply with all cily Imd county ordinances and state laws chung to Qpy, MF,CIIANICAI,PERMIT FTSE j tj
s U z building construction,slid hereby indication ..arion representatives of this cityenter upon the EISMIC FEE
i above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree,.save.indemnify and keep harmless the City of Cupcnino against ELECTRIC IL[
!s
liabilities,judgmentpense
s,costs and exs which may in any way accrue against said City ALTER OR AILD TO MSCI I.
i[ tsrnperecor the,rnnfn,af this pmol. PIAMIiIN 'IR�`
r APPLICANT UNDERSTANDS AND WILL COMPLY WI'I H ALL NON-POINT AIR HANDIANO UNIT(TO 10.000 CFM) MECHANICAL FEF,
SOUR'E REGULATIONS,
�
AIR (OVIA 18.(00M
CONSTRUCTION TAX
S' « fAp ca tUnto EXHAUST GOOD OVIDUCT) HOUSING MITIGATION FEF
HAZARDOUS
MAIldfiri neau,n tstoreDISCLOSURE
Will the vppliam lir littera M1uilJing acenpam sorra or handle hazardous motorial HEATING UNIT('10 100,030 n'I'If)
as defoted by the Cupertino Municipal Coda.Chapter 9.12,and the Health and Smal,
Code.Section 255321a1? HEATING UNIT(OVER 100.000[]TO)
E3 yes []NO VENTILATION PAN(SINGLE RESID) PAID
Date Receipt X
Will the applicant or lulus haildiny omntpant ase hgtipmenl lir devices which BOILER-COM P(3 HP OR 110,0(in BTU)
mit hamnfuus air csmtamlnams as defined by the Bay A.,At,Quality M....cmem TOTAL40 :
Danno? BOILER-COMP(OVER 100,0( BTU7
❑Yes ❑No
I have read the facial.,,materials regniremems maker Chapter695or the Cali- ALR CONDITIONER ISSUANCE DATE
forma Benin&Salary Code,Sections 25505,25533 and 25534.1 undersand that if the NEW BE SIDE MECH. SQ.FL
building Joos not currently have a tenant,that it is my reerymsihibity m notify the occupant
of t�amems which must be mei prior m issuance al s Ce9ifica f Occupancy.
-Y-rlm. ono 6,c
Ons u'uut7l nova a,em ! Dam - TOTAL: ISSUE])By.
OFFICE
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
BUILDING PERMIT INVOICE OPERATOR: chrietya
Sec: Twp: Rng: Sub: Elk: Lot:37507059.00
INVOICE DATE......: 01/03/2000
REFERENCE ID # . ..: 00010001
SITE ADDRESS .....: 10219 JUDY AVENUE
SUBDIVISION ...... .
CITY ......:. .....: CUPERTINO
IMPACT AREA .......
OWNER ............: GOVIND TATACHAZI
ADDRESS ....... ...:
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
CONTRACTOR ..... .. : LIC # -
COMPANY ..........:
ADDRESS .......... :
CITY/STATE/ZIP .... ,
TELEPHONE ........: -
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- --- --------- ------------ --___---_--
BPVENT P 8.33 0.00 8.33
PPERMITFEE P 35.52 0.00 35.52
--------- ------------ -----------
43.85 0.00 43.85
V ID DESCRIPTION .... VOICE ID --- - DESCRIPTION
. ........................ ........ ........................
SEWER 4 WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 302 TUB 4 OR SHOWER
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING