00010030 (2)' APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY D 3
CITY OF CUPERTINO BUILDING-ELECTRICAL11 PERMIT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. SOOOI
BUILDING PROJECT IDF.NOFICATION
e BUILDING ADDRESS: - SANITARY NO. APPLICATION SUOMI"1'1'AL UATI
2 0 oc
WNER'SNAME: PHONE: CFZ4TRACT0RSNA E: LIC NO:
NIC C ON'I'ROI,p
s NCHITF.Cf/IiNGINEER: LIC NO: ADDRESS:� ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Cnnsaltant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
❑ ID
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT PEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(rommencing JOB DESCRIPTION
'00ngz with Senion9IX0)of Division 3ofmc Bustiessvnd Prrfcxion,CWe,and my license is RESIDENTIAL
WOO PGNMII'ISSUANCE
H� in full forte and eBect $� ❑SFUWL ❑KITCHEN REMODHI.
aVZU License ClassC`g0'�-.3�" Lic.11 APPLIANCES-RESTDEN]IAL []ADDITION ❑PLUMPING BE PIPE
FGW Dam I-10 �sw CommI ."MCINE
ANCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCfURAI.
ZOmZ Iundersumd my plans shall beuseJ as puhllcrecords PANELS MODIFICATION
UPT0200AMPS
OZ4O ❑INTERIOR ❑CHIMNEY REPAIR
I..aoI- Licensed Pmtcrsional 201,.2)IAMPS IMPROVEMENT SWIMMING POOLS
g� �i
. OWNER-BUILDER DECLARATION OVER IIXOAMPS El BATH RCMODEUREPAIR E)DEMOLITION
3:W 2214'' I hetchy affirm that I am eaempt from the Commcmrs License Law for the
S(O 2 U following reason.(Section 90111.5.13usiness and Professions Code:Any city or county SIGNS ELECTRICAL 0 OTHER 1
1+1311 yd which requires v Permit to common,alter,improve,demolish,or repair any s0ucmre
F-r4�O.] prior m is issuance,also requires the applicant for such permiuo file v signed stmcment SPI?CIAI.CIRCIII'f/MISC,
ythat he islicensed Pursuaento the provisions ofthe Contemner License—.L..aptcr9
I+)�p0 (commencing is ith Section 71000)of Division 3 of the Business and Professions Code)or TEMP METER(1H POLE INST. COMMERCIAL•
2 y tY that he is exempt therefrom and the basis for the alleged exemption.Any Golmion of NEW BLDG/ADDITION ❑DEMOLITION
Www Section 9031.5 by any applicant for v Permit subjects the applicant o a civil family of POWER DEVICES ❑TENANT ❑FOOD SERVICE
u more than live hundred dollars 145011. IMPROVEMENT
TSC ❑ Las owner ofthe propcny,or my employees with wages affixamb,mentereatimm SWIMMING POOL ELECTRIC
y will dothe work.and the sweture is not intended or oRcrcd for sale(Sec.7044.Business ❑OTHER
s2i1 ESQ and Professions Cade:The Characters License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves Ihe..,and who docs such work himself or through
his own employees,provided that such improvements ore not imended , r Ii 'CID L E C FT.
sole.if.lmwever,the building or improvement is sold within one year of erns SQ.FT.MOOR AREA $/SQ.F.
mer-builder will have the burden of proving the he did nut build or imps
pxeofele.). MOWN= W
❑ 1,as owner(if the property,am c clusivcly contracting with IieenseJ con rrs m A
construct Ne prajecs(Sec.90,14,Business and Professions CW<:)The Caalectoe:
cense Lin,dors not apply mesa owner of progeny who builds or improves thereon. Q 1 FEE
who contacts for such projects with a contralmdut licensed Pursuantto the Culture s 10M
License Lw. 1,
1 am eaempt under See. .B&P C far this ream
)wher Dom_ D N P ( VALUATION
WORKER'S COMPENSATION DECLARATION C 'R D
I hereby dFum under penalty of 111.1 one of the following declan ot as
❑ IhavcandwillmaitnainaCenificateof Conwntioself-insure far Worker s 'h.I'. DR S-M ,RO ,A F.A, STORIES TYl'ECONSTRUCf10N
inion,as provided far by Section 3900 of the Labe Code,for the performance of the
work for which shin permit ie issued FIXI'UREB-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,ox required by Section
3700.1 the Labor Cade,for the performance ofthe walk for which shin permit is issued. GAS-EA.SYSTEM-I INC.4 OU'ILETS (ICC.GROUP
My Workers Compensation Insurance carrier and Policy number are: 3
Currier. Policy No.: GAS-EA.SYS'I EM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRI?ASPIINOUS'I'RL WASTIi INTI?NCGPI'OR
COMPENSATION INSURANCE BUILDING DIVISION FEES
ITbissectionneedem Meme,leted ifthe Permitilfo miallandreddullan(SIM) GREASEIRAP
or less.) PLANCIIECK FEE
lrertify shay in the Perfnrnunce of the work for which thio permit is issuW,Ishall SEWER-SANITARY-STORM EA.2IXIIT.
nm empl y rs i y manner so came rhbjat m the Workers'Cout ENERGY FEE
,'� ration L Ifnrnia t WATER 111?ATF.R WNENT/F.LECTN I f i---
NOTICE
�'
C) 0 onionAppliau nn nano as� GRADING PER
q rNs NOTICE T APPLICANT.11',one,making this Certificate of Exemption,you should WATER SYSTEM)TREATING
a , beasme subject m the Walkers Compensation provisions of she Labor CWe,ye.must SOILS 1' `/
W Q forthwith comply with such provisions or this Permit.chat[be deemed revoked. WATER SERVICE I U
C1.
CONSTRUCTION LENDING AGENCY NEW RES[DEN TIAL PLMIL SQ.IT. PAID L
V O l hereby affirm that there is a construction lending agency for she performance of --DJAN
Re ip
the work for which this permit is issued(Sm.3097,Civ.CJ
0 U Lender's Name TOTAL.
W Lendees Address TOTAL:
0. I rtify that 1 have read this implication and stale that the above information is BUIL LNG PEIi
ce
h correct l agree tocomply with all city and county ordinance and state laws relating to QTY. MECHANICAL PERMIT FEE r
V z building chnstnmtiontmd hereby roman.mmeumotives admix city mentefupon the SGISMICPF.Pr ��,
`+ above-mentioned property for inspection Purposes. PERMIT ISSUANCE
(We)vgma m ame,indemnify and keep harmless the City of Cupertino aguinst ELECTRIC FCL'
liabilities,prin ms,costs and expenses which may in any way accme against said City ALTER OR ADD TO MECH.
PLUMPING FCC
in consequence of the grvtting of this permit
co
APPLICANT UNDLRSTAN WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'I'(TO 10.000CFM) MECHANICAL FEE
ItEGULATIONY I -
_ yZ. AIR HANDLING 11Nl'1'(OVER 10,000 CFM) CONSTRUCTION TAX
T."'dep"W"
ntren AAP ont/C mmctar Dato I:XHAU$T HOOD(WIDUCf HOUSINGMITIGATION fTF
HAZARDOUS MATERIALS DISCLOSURE
ll the applicam or future buildingrccumant same or handle hauntims material IIEA'I'ING UNIT GO 11X1000 BTIB
tuby lbe C.,ma.Municipal Code.Chapter 9,12,had the Itru th and Safety
•Section 2553200? HEATING UN1'I'(OVER 100.100 B'SO)
E3 Yrs ❑Nn VENTILATION FAN(SINGLE.RE.SID) PAID --
Dee Receipt p
Will the applicant or future holding occupant use equipment or devices which
emir hamrdhus air mountainous as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 1(0,000 BTU) TOTAL: 33
District? BOILER-COMI'(OVER 11X1^1% 13'1'11
❑yer El No
I have read the heard,,.,materials requirements under Chapter 6.95 of the Calm AIRCONUIHONER ISSUANCE DATE
fornix Health&Safely CWe, s 25505,25533 and 25534 1 underswnA the if the NEW RESIDENTIAL MECH. SQ.FI'. 1 -16 LQ V
buil ' otcuneml a ao .that:!is myrespansihil'ny to notify the oecumuet
to s hi t prior ns issuance of.Croufrm,af0ccupanry.
Owner s a...g agate Uma TOTAL•° ISSUED BY
OFFICE
'INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
• BUILDING PERMIT INVOICE OPERATOR: chrintya
Sec: Twp: Rng: Sub: Elk: Lot:31633082.00
INVOICE DATE......: 01/10/2000
REFERENCE ID R ... : 00010030
SITE ADDRESS ..... : 10446 PRUNE TREE LA
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA ... ....
OWNER ............ : STEVENSON DOME E AND ANN L
ADDRESS ..........:
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-2023
CONTRACTOR ....... : LIC q
COMPANY .......... :
ADDRESS . . ........:
CITY/STATE/ZIP .... ,
TELEPHONE ........:
FEE DESCRIPTION CHR TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- _-- _________ ------------ __--__--___
BREMAIRHAN P 8.33 0.00 8.33
BUSLIC P 90.00 0.00 90.00
MPERMITFEE P 35.52 0.00 35.52
--------- ""'""---- """""--
133.85 0.00 133.85
ID DESCRIPTION VOICE ID DESCRIPTION
........ ............................ ........ ............................
204 UNDERFLOOR FRAME 301 ROUGH PLUMBING
303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL 514 FINAL PUBLIC WORKS
•