00010064 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELBCTRI L PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING•MECHANICAL. S0001
BUILDING PROJECT IDFN TIRICATION
HULLOING ADDRESS: SANITARY ND. APPLICATION SUBMITTAL DATE
Ra T
OWNERS NAME; PHONE: CONTRACTORS NI� LIC NO: N/C CONTROL Is
RCHITECTfENNGG•INEER: LIC O: ADDRESS: ❑
Ge pn/
CONTACT,, PHONE: �Iss�� BUILDING PERMIT INFO
Z 950 y g ❑ Cnnsul[an evs�'9ia By AppBc3H� 1) RL❑DG ELECT PI.UMIt- MF❑CH
LICHNSED CONTRACTOR'S DECLARATION 7 QTY ELECTRIC PERMiT FEE lrr�i/
I heresy affirm that 1 on licensed under provisions of Chapter 9(communicant; QTYDESCRIPTION
QaZ with Sstion]001DofDivision 3 of the Bminess Snit Profiamors Coduandnry license is R SID NTIAL:
Q n full force and eRec PERMIT ISSUANCE
CSF i 0SPOWL O KITCHEN REMODEL
F fJp License Class Lie.N APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPIT
N ZG u] Da¢ Comntc�• �J
FQy ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL.
r�Z 1 understand my plane Nus
Nall he ed as public records MODIFICATION
OZ- UPT02MAMPS ❑INTERIOR ❑CHIMNEY REPAIR
[[:Q.4I Licensed Professional 261-HMOAMPS IMPROVEMENT ❑SWIMMING POOLS
C a� OWNER-BUILDFR DECLARATION OVER It100AM1'S ❑BATH REMODEUREPAIR ❑DEMOLITION
C' a I hereby alEnn that 1 am exempt from the Contractor's License Law for the
�Lpd O L U following reason.St7031.5,Business and Professions Cale:Any city or county SIGNS ELECTRICAL. []OTHER
LL O y email m m
which requires a pit construct,alter,improve,demolish,or repair any sneture
I- G
C"' murtoitissuacon,almre,dresmeappliend for such penntIn filersignadmmananl SPECIAL CIRCUIT/MISC.
2 y that he is licensed pursuant o the provisions ofthe Contnutot's License Law(Chapter 9
(commencing with Section 7M(fof Division 3ofthe Business and Professions Code)in TEMP.METER OR POLE IN COMMERCIAL
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION O DEMOLITION
Section 7031.5 hynnyappllcumfor a permit,uhpals thenpplicam to a civil penally of POWER DEVICES OTENANT ❑FOOD SERVICE
I more than five hundred dollars(5500), IMPROVEMENT
QOLusnwnerofthepmpeny,or my employees with wogcs as their sole can.penurtion, SWIMMING POOL ELE
Q willda the woA,and the stmmure is not intended moRered for sale(See7] ,Business ❑OTHER
and Professions Coda The Contractor's License Law does nm apply to an owner of OUTI.11'TS-SWI3" :S- ' ONES
a J4
pmpeny who builds or improves theteon,and who does such work himself or through
his own employees,provided that.such improvements arc not intended ar offered for NEW RESIDENTIAL k.FCT415
sale.If.however,Ne buildingor immovemem is sold within one year ofcompletion,the SQ.FT.FLOOR AREA $/SQ.FT.
er-builder will have the burden of proving that he did nm hull)or improve for pun 10
pose of sale.).
1,as owner of the poo,vriy,am..elusively am in,dr,with licensed contmetoo m
construct the project(Sec.7041,Business and Professions Code:)The Contractors Li-
censelawJoesnotapplymanownerofpropertywhobuildsorimprnvestbcrcon,and QTY PLUMBING PERMIT FEE
who commons for such projects with a conwccoms)licensed pursuant o the Contmmoes
License Law. PERMIT ISSUANCE
❑1 am exempt under Sec. ,B&P C for this reuon
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Data
WORKERS COM PENSATION DECLARATION BACK FLOW PROTECT.DEVICE 15-400.9I hereby affirm under penalty of Perjury ane of the following declarations:
O lhuve unA will nmintnin aCertifcnte of Cansem mself-imure for Wnrker'e Compen. DRAINS-FLOOR,ROOK AREA,COND. STORIES '1'YPECONSTRUCf10N
motion,as provided for by Section 37W of the labor Code,for the performance of the
work for which this psmnit is issued. FIXTURES-PER TRAP
O L have and will nainmin Worker's Compensation Insurance.as required by Seninn
371X1 of the 1.ahor Cn c,for m e trance of ework for which this permit is onion, GAS-ITA.SYSTEM-I INC.4 OUT LETS OCCGROUP APN
My Worker' n 1 'ce caret of cy Nd In oY n GAS-EA.SYSTEM OVER 4(LA)
Gorier. —L or -v J7
CEU1171CATE OF IIENIfTION FROM WORKERS' GRFASPANDUSTR,WASTE INIFRCEP1'OR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need nottecompleted B the permit is forone hundred dollars(SIM) GREASETRAP
or less.) PLANCHF,CK FEL
L certify Nal in the performance office work forwhich this Permit is issued,l shall SEWER-SANITARY-S'FORM EA.260 IT.
not employ any person in any runner so as m hecoma mijccuo the Workers'Compen- ENERGY FEC
Qz sation laws of California.Dam WATER HEATER WNENTEL.ECTR GRADINGFF:E
0 Applicant
y NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER$YS'IEM/1'REATING
a hecumo subject to the Worker's Compensation provisions of the Lahor Code,you nest SOILS THE
LkI forthwith comply with such provisions aphis pemdt shall ba deemed revoked. WATER SERVICE
a Q
UO
CONSTRUCTIONis1.ENDINGAGENCV NEW RESIDENTIAL PCMB. SQ.1T. PAID Date Receiptk
I heresy afOrm that theree is.a comnamnion lending agency for the perfnrmmce of
the work for which this permit is issued(See.3197,Civ.CJ
I••' Landers Nairn, TQI'AL:
WLender's Address TOTAL:
I certify shut 1 have mud this application and state drat the ohove information is _ BUILDING FEE
TSA comstf l agree to comply with all city and county ordinances and state lawsrelating to QTy, MECHANICAL PERMIT FEE
V Z building consimefion,and hereby authorlec representatives of this city to enter upon the SEISMIC FEE
aMve-mentioned property for inspection purpmea. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupenino Radical ELECTRIC PEE
liabilities,judgments,cons and expenses which may in any way acerae against said City ACIER OR ADDTO MECIL PLUMBING FEE
in nsequenee of the granting of Nis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1.NON-POINT AIR'HANDI.INO UNIT(TO 10,(XM CFM)
SOURCE RGGULA'I'IONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER I gQMI CFM) CON ST RUCTION TAX
Signature mf ApplicandConuamor Data EXHAUST HOOD LW/DUCT) HOUSING MI"I'IGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Willlheapplicuramfumre buildingoecupanl some oehici le bezaNaus mtord.1 HEATING UNIT GO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cole,Section 255320)? 1HEATING UNIT(OVER 100,000 BTU)
❑Yes FIN. VENTILATION PAN(SINGLE RE.SID) PAID
Will the applicant or future building occupant use equipment or devices which Data Receipt#
mil havardous air contaminants as defined by the Bay Ann Air Quality Management BOILER-COMP LIMP OR 100,000 BTU)
District? TO'T'AL:
❑Yes ON. BOILER-COMP(OVER IMBM BTU)
I have read the haeandous mmerials tequitemenw under Chaper 6.95 of the Cali.. AIR CONDITIONER
ISSUANCE DATE
forme Heulth&Safety Cale,Sections 25565,25533 and 25534.I understand that if the NEW RESIDEN'NAL MECH. SQ.PI�
buildingdtes not currently have a femur,that it is my responsibility to notify the occupant
el the requirements which must he met prier to issuance of a Certificate of Occupancy.
Owner or authorized agent 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: Lot:35623035.00
INVOICE DATE......: 01/12/2000
REFERENCE ID # ...: 00010064
SITE ADDRESS .....: 21555 MONROVIA ST
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: LUMANG RICHARD D AND ETHEL C
ADDRESS ....... ...:
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-4803
CONTRACTOR .......: GUSLANI, CHRIS LIC # 21311
COMPANY ..........: HOT WATER INC
ADDRESS .......... : 2531 GRACELAND AVE
CITY/STATE/ZIP ...: SAN CARLOS, CA 94070
TELEPHONE ........: (650)298-8494
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
ID - DESCRIPTIO---------- VOICE ID DESCRIPTION
... ...... ........ ............................
6 SEWER a WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 302 TUB 4 OR SHOWER
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
•
WPN.10.2000 10139RM MIETCLERK INC &0.897 11
CITY OF CUPERTINO
BUILDING PERMITOPLICATION
10300 Taro Ave. CUPKIIIIe,Co.86014
(408)777.M8
i
PROJECT ADDRESS:21411115 MONROVIA er 9LDG 9t
SL)ITIVAPT#C
PROPERTY OWNER CONTRACTOR
OWNERS NAME; LUMAN0,RICHARD
tat wear Ina4D489eae
MAILING ADDRB@S216i6 MONROVIA ST MAILINGADDRESpr
CITT/STATUIP: CUPERTINMO Crab Dlaeaurta as
66014 C ATE/jtP: een cam" CA D40f0
PHONE( 4"Z67366a RAXdt ( ) PMONBik( 660J n46aae FAX ( 68gRG8e4D3
HAIL ADDR868 84MLADDII IpualarIT&GLoom
BUSINESS LICENSE 0 71711
LVTAZN WORK TO BE PMWOBMSD; REPLACE WATER HEAT
E
87d=m K31=ICAL
XKRANC9� FLTJk®tNG; ✓
BZROOT. RAZAAD006 Fdt6 4U&J Will � NO Numu cirSXI6mNo wor cov {bw o
TYPE W vmm NG AOOF COvva*
PAOP06>m AOOF COV>t�0:
NUNmo7mG9TmAOOFO0veA>1vw=Wvu, 0
NUJI=OFS;vu NOAOOPCOvzRv,wpxrAm:D
PAovLpg LCA.O,RFXOATNO. Otl.DO
vALUw1iO)a,
• IMPORTANT NOTICES NoneeToAPPLICANT
APPLIGLNI cuMFICATION I I'domw smrm cedar parow of POW om of III amAn9 deWAlbne
ICBRY'lli
904INFORMATION
FORMI ION ItCORRHISAPPLICATIONANDSTATETHATTHE 1 > IhawtmdwAmrlhmawremaOfdiIdru111411111111-pbn'eem.
A80VBINPORMATION6ICORRIIIIAGREE THAT IFAPeRMRW19. PwaoonapaV by 8.a 3700dyaLowCode,,hrftP@F%nna,m
SUED FOR THE DOWLRIONDESCRIED ISTHISAPPLICATION.ALLTNB ddawork WNehWell 1114Wo d
PROVISIONS OF THE PERMIT AND ALL LAM AND OMINANQBa
THERTOWILLBECOMPLIED WRN. 1{ IhmowwonWnminroft ownp~meilmraimm.u�lrtleyaw
GMOno drew 60barOW& .Me wfwma dw.arkrorw"m
HOLDHARMLILS9ClAUMper
S87mRee(s)bYaoLepanpedlMe a
nyw►Aa'mmeerw6onlrawe ceaaMwandpdignun
e0me(a110 hdrnNy and hold hwnfaw dta 011y e(Cupattlrto papdL Massm and I CenlOr elate Nftd
sorad any and an delme,domerda and atsbna tar demean reauldnD eom
apPhOt d �ambn
glider 1hm P@mk ta8erd on d mlllGenoa d ai the Cly d Cupwbo Pswk~ 1649388
dah%domande Ofada. < ) T?"am
m°e of ca
to prevf lc"Of omothdadbn 360 of4m"u der(0. o c dul t 1 nr lw"duan ale Uffwmanta due work larwalah f4 parma m I Wd,l
the
amu d GOmm4,tlIa ePORtarll shall Ave ee.arkGs under(�,W(w daala
nand below orohd Irfdlroa 111010,m &hall rat wow Ory paraen in any naroarao u m beamrw w b rarlr
Y hewnvN Ram M m choWd RanlM a M.whbnaw u sppRwab. sm oompmaWon mea d cm my IMaw ee to bedoa eou f undamdnd
efroroprta4 modlad d oamplhna (M mold b eMokod u wdL Mark Ilia I tM In u»enitteat I eMw!beaw a Oubjed m da wawa'wmwn6n
Prardelene*lure Labor Code of gaernm and fie b WHO famph t 0,111%
LICm1a6D Wowli yid daaCeen 3600 Of em Lebo CWa,dill dle Penne harem Marled for
I aann eW l em�CONTAACiOM Da0lAAAT10N ahM M deemed re`okad.
wmrwauwrhrwnesdot�narM t I a�leoAMnda oeTnr(area
aArtaa'�aa0°r Ord
763612 e6a+fkrthewnMaNNdmaedennarwdd,e
793614 pI mimed,t Par employ O aaneaelorwfle eomp4u
W°gae��cwu=`M OS181/2001 m.na "I'"'y fee"Of Cm*d and who,pme ir wiu a:central
tNroit WNau.
PAYMENT
AeeeuNr�; a (6 „7
• IRw N ap
CA4DIT CARD TYPi � Till;NM18 ON I,ARy, /Or11
eI A8f ,
AMOUNT s
mpnab re dMN cared Doe ba r
werme win.dAooroent
W9N.10.2000 10:39W INETCLERK INC rP)0 897 FP-AS
NetClerk, Inc., ; *4W&jjgW* pgk"
650DOU"Avenue
south 1m Frwndlee,CA 14010
41-. . (911) 11 CLERK
ffon
IftxNamber.
NetClerk Inc. Tbt Building &planning Department
0met Boom Wa trbwy CH(630)6240416 Phoow (408)777.3226
-077)146-5889 70 Number: (408) 7773353
Permit Handling Instructions
?lease Pa:Permit to:1.(877)8168888 DrJivor to job site at Sr1t impecdon
I wIU plait permit UP at the DuUdInB Department in 3 dagr R Please nail eli�aal to Contractor luldreaa below
Osbert
Contractor Information
Company; Rot Wtuw Ins. Worker's Comp Ah 1540"Stats Fund
Caawetor: Stam COMMOmr'1 Licen"M ?"612C36
Addrama 2591 Oraoaland Credit Card Information
Cly.- Ban Carlos,Ci 91070 CreditGard Nambert 42463115.01171678
Phone: 650.298.8494 Name on Card: Chdo P.Oushw
1 >r 650.298.8493 11*84 n Data 06/00
at SIMON il: VW
sSattorCard
Comments:
Fitz
Authorization forma: Credit Card authorization
Yaw alsNrGrlr.MYMrwyntmreeWr{C �
_ f
LItMNatwaAbglNrtGGrl/AieddllY.epyrylorlN �
dHrOnkparemmayrr�w
�t+rWhrM�oralleerrnpor;y vOMM; Cr...
]Two omw N�rr a
d10aletK�/� /, ' - 'DCditCtal/i j�$�eltaa�m� �fj
Mery A.:a
weietLt�