99080204APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO _
SIDE MBINr..MECII ELEC R
BUILDING DIVISION APPLICATION/PERMIT rINCP@1G:M EDEN
'urn ntNf.-PRI11DfT II1F:N'I
:'III-'% Z)ig-o J per. L_ W
CHITECr/HNGINEER: LIC NO.
ADD
(A
ESS:
TA Silt ti n
'-
CONTACT'. PHONE
BUILDING Pr:RM1T INFO
Ii;.17 EI.HC'IPLUME MI!CH
❑ Consultant Fees Paid by Applicant (Initial)
❑ Fr— ❑ P-�
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that L atm ]accused under pmrionas of Chapter 9 (commencing
the Licipess anA l'rnfessiotw CnJc and mylicenseie
in ear force Jefied� -C�l 60 6�
Lmcreorce of effect.
L
QTY. ELECTRIC PERMIT FE13
_
JOB DESCRIPTION
RESIDENTIAL
❑SFDWL ❑ KI'r'CHEN REMODE
❑ADDITION ❑PLUMBING RE -PIPE
❑MULTI -UNIT' ❑S OD[F[CAAO
MODIFICATION
❑INTIiR10R El CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
09 Z BOI-
LL-
Q U
FFZW
NQ1
I ZOr2Z
O Z Ln
{Oil
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
PANELS
UP TO 200 AMPS
Dmc Cnntmctor_114
ARCHITECTS DECLARATION
lu JersonJ my plum shall be useA ns puM1lic records
Liceroed Professional
201.10XIAMPS
�GGG
iG .J
O LL Q
O a V
3
OWNER -BUILDER DECLARATION
1 hereby nffrm ohm 1 um exempt Is a the Commdor's License Law for the
following reason. (Section 7031.5. Business and Cale: Any city or county
do o
❑11A'TH RIiMODElIRIiI'AIR [:1 DEMOLITION
❑OTHER
OVlilt 1000AMI'S
SIGNS ELECTRICAL
LL F'
is structure
improve.
whish requires a permit oc construct. ober, improve. demolish, or repair any statement
prinrtn its lheapplic. such le aelulemem
SI'IiC1AL C111CI11T/MISC.
ymal
p0
110.cf�
XmR.
W
F=Q
i D❑
ML.
W 3
censece,alsnmluiree
Contractor's a,
he is licensed pursuant In the provisiann of the Gmoadorm License Law lChuptars)
of the
(commencing with Section 7000) of Division 3 of the Business and Profession, Code)or
e alleged eption. Any vialmion of
that he is exempt ihcmfmm and the basis for mxem
Section]031.5 by any applicant for a permit subjects the applicant ma civil penalty of
nal oure than lira hundred dollar, ($501).
bus ownentl the ro n,nrm to ees with wu es av theirsole utm nsmion,
t st y Yot in Y g M
will Jo mework, and the stmnure is not intended ontfkreditr role (SecJ(FW, Business
and Professions Code : The Contractor's License Law Aces not apply m an owner of
property who hailds or improves thereon, and who Jocv .such work himself nr through
his own employees, provided that such improvenmms we no intended or nflbree for
safe If, hc,cvcr. the building or improvement is said withinone your of compldinm,the
TEMP. METER OR POLEINS'(.
COMMERCIAL'
O NEW BLDG/ADDITION El DEMOLITION
❑lENAN'I' ❑FOOD SERVICE
IMPROVEMENT
H
POWER IiR DEVICES
SWIMMING POOL ELEC'T'RIC
OITrE.I?TS-SWI'T'CHES-FEX'NR&S
NEW RESIDENTIAL [LECI'R SQ Pf.
yQ. FMFLOUR
4SU IT.
moult- wilder will have the burden of proving that he did not build nr improve for par-
TOTAL:
pose or,ale.).
1, as owner al the property, am exclusivelmaintainimaintainingnsed toning with licecomracm
I/G•
-
QTY. PLUMBING PERMIT FEE
consumer me project (Sm. 7041. Business and Professions Gale:) The Commutes Li"
verve Law does notnppIy in an owncr of property his buildsor improve, thereon,and
who contracts lin such pn!iccls with o commcroms) Beamed punuanuo the Commear's
P17RMIT ISSUANCE
License Law.
❑ 1 am exempt under Sec. . B & P C for this reason
Data
ALTER - DRAIN & VENT- WATER (HAS
VALUATION
watt
xf WORKER:S COMPIINSA'I'ION DECLARATION
[hereby affirm under penalty nfperjury one of the following declarations:
IhuveaodwillmaintainaCenifcaa of Cnnwmmulf-insum for Workers Cnmpen-
smlon. as provided for by Section 3700 mf the Labor Code, for the wrfa ustar, of the
work far which this permit is Issued
HACK PLOW PROJECT. DEVICE
DRAINS- FLOOR, ROOF. AREA, CONS).
STORIES
TYPE CONST RUCTION
FIXTURES - PER 'TRAP
❑ I have and will maintain Worker's Compensation Insurance, as usmimcl by Section
3100 ofine Labor Code. for the serfornameo,ofsue work for which this worth is iasoed,
GAS- IiA. SYS'I'I'm I INC. 4 OEM L HIS
OCC. GROUP I
My WortVAi6bla,mmunce tamer and Policy�nuty�t�ry¢ ^(s -s 8
Cnrtler: Policy Nn,lAl<-3 Lir` I�
ZAl%
CAS -13A. SYS'fIiMOVER 4(HA)
GRPASFJINUUS'rRE, WASTE INTERCEPTOR
dwirICATF. OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
BUILDING DIVISION
PHIS
f'Ifiis section need not be completed ifthepennit is Inrnne hundred dollars P$I01B
nr less.)
GREASETRAP
PLANCHECK FEE
SEWER -SAND'ARY-STORM EA. 200 ITP.
ENERGY FEIi
{Z,
O�
r" 1
Wfonhwitb
�z
L%0
(L (•+
Ll
W
Cie)
U Z
11 pernnrmance nfthe workfor which lhlspc tit is.... IL Jobs"
I cenif mot
not employan of any= rncesnnsmheron suhjn h Workers'
satiori aws of lif is a
Applicum
WATER HEATER WNEWAIL.ECTR
GHAI)IN(1FE6
NOTICE 111 ICA T: If, after making this CY! u o
become subject nt )e Worker's Compensation provisions of the .al o Code, you mut
comply with such provisions or this permit shall he deemed mottled.
CON.S'IRUCTIONLENDINGAGENCY
I hereby affirm that there is a construction lending agency for the peubrrttunce al'
the work for which this permit is issued (See. 3097, Co, CJ
Lsnder's Name
WATER SYS'I'EMRRF.ATING
WATER SERVICE
SLj
I IXf FEE i—x
Is
t;.
I),
f 111 9t�j�J
9S1DJ
N17WISESIDFN'I'IALPLM It. SQ. FT.
TOTAL:
'TOTAL:
QTY. MECHANICALPERMI'T FEE
Lendcr',Address
1 certify that I have mind this applicutinn and state thanhe above infnnnminn is
cori l agree at comply with all city and county ordinances andshim laws relining to
building communion, and herebyaathoriu representatives of this city to enter upon the
H
11�(�lG FEE
SEISMIC
FEE
PRIME r ISSUANCE
ELIiC'I'RIC PEE
a soe-mentican d property fill inspection ImPnscs
s• indemnify and keep harmless the City of Cuperim against
(We) agree mave
PLUMBING ME
-
Iiabilities,judgmems. costs and expenses which may in any way accrue against said City
incnnseq turn( thegramingofthispemtit
APLIC T UNDERSTANDS AND WILL COMP TVA[j, NON-IfANT
ALTER OR ADD TO MECIL
AIR HANDLING UNET(TO1E0010CF1,)
MIiCHANICALFIE
St 1RCE WGULATLONS.
AIR HANDLING UNIT(OVER I10.000C17M)
CONSTRUCTION TAX
is fAp,l,c.nV nlmnnr Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCO
HOUSING MITIGATION IIiIi
HEATING UNIT Cl0100.0(X) BTU)
Will theoppluoutnr Future building nccupam sutre or handle huzallou....a at
as defined by the Cu istman Municipal Cade, Chapter 9.12, and the Health and Safety
Code. Section 25532(a)7
- HEAT'ING UNIT (OVER 100.100 BTU)
YHNITLATIDN PAN (SINGLE RESIDE
E) YO, Nn
PAID pane Receiptk
ll She applicant or future building uccury' of use equipment nr devices which
ururdnus air cantard...is as defined by me Bay Area Air Quality Management
Icli
BOILER- COME' DHP OR 100,(100 BTU)
L,
BOILER - COME'(OVER 1011,100 BTU)
UrW
❑Yes
AIR CONDITIONER
I have re ad rhe hmsNnus materielstequimmetitsmi ICTapter6.5of tbe'ali-
1n iia lic-b Safety CW0. Sections 25501, 25533 and 2553.11-.1e ane sun f the
bt dingJ notauready huventenen6 ohm it is ntsibility to nn ry tact apwt
�f ISSUANCE DATE
`4 �� f"] ^ Q
NEW Et1iSIDEN'PIAI. MF.CI I. SQ. FT.
of to reR ¢room., Ce
'TOTAL:
ISSUEDBY:.- f "�-
Owi •nn authnriecJ agent, D a
OFFICE
• �J
CITY OF CUPERTINO
•3� 1 of 1 BUILDING PERMIT RECEIPT OPERATOR: kareub
COPY,# : 1
Sec: Twp: Rug: Sub: BIk: Lot:36222040.00
DATE ISSUED.......: 08/30/1999
RECEIPT #.........: 9921
REFERENCE ID # ...: 99080204
SITE ADDRESS .....: 7713 ROBINDELL WY
SUBDIVISION .......
CITY ....-..........: CUPERTINO
IMPACT AREA .......
OWNER ............: GUSTAVSON GRANT C AND PHYLLIS
ADDRESS ..........:
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
TOTAL RECEIPT 111.00
VOICE ID DESCRIPTION
........ ................
303 ROUGH MECHANICAL
505 FINAL ELECTRICAL
VOICE ID DESCRIPTION
304 = ROUGH ELECTRICAL =
508 FINAL MECHANICAL
RECEIVED FROM ....:
TIM
CONTRACTOR .......:
HUSSEY, STEVE
LIC
# 20758
COMPANY ..........:
HUSSEY BROS INC
ADDRESS ..........:
640 TAYLOR AVE
CITY/STATE/ZIP
...:
SUNNYVALE, CA
94086
,
TELEPHONE ........:
(408)733-6360
FEE ID
UNIT QUANTITY
AMOUNT PD
-TO -DT
THIS REC
NEW BAL
----------
BREMACOVER
-----------------------
NO UNITS
1.00
--------------------
14.43
0.00
----------
14.43
----------
0.00
BREMMISC .
FLAT RATE
1.00
25.53
0.00
25.53
0.00
M�TFEE
FLAT RATE
1.00
35.52
0.00
35.52
0.00
E TFEE
FLAT RATE
1.00
35.52
0.00
35.52
0.00
TOTAL PERMIT
---------- ----------
111.00
0.00
----------
111.00
----------
0.00
METHOD OF
PAYMENT AMOUNT
NUMBER
-----------------
CHECK
------------
111.00
------------
------------------
14324
TOTAL RECEIPT 111.00
VOICE ID DESCRIPTION
........ ................
303 ROUGH MECHANICAL
505 FINAL ELECTRICAL
VOICE ID DESCRIPTION
304 = ROUGH ELECTRICAL =
508 FINAL MECHANICAL
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
• BUILDING PERMIT INVOICE OPERATOR: karenb
Sec: Twp: Rng: Sub: Elk: Lot:36222040.00
INVOICE DATE......: 08/30/1999
REFERENCE ID 4 ...: 99080204
SITE ADDRESS .....:
7713 ROBINDELL
WY
SUBDIVISION .......
---
P
___-__---
14.43
CITY .............:
CUPERTINO
P
IMPACT AREA .......
EPERMITFEE
OWNER ............:
GUSTAVSON GRANT
C AND PHYLLIS
ADDRESS ..........:
P
35.52
CITY/STATE/ZIP ...:
CUPERTINO, CA
95014
CONTRACTOR .......:
HUSSEY, STEVE
LIC N 20758
COMPANY ..........:
HUSSEY BROS INC
ADDRESS ..........:
640 TAYLOR AVE
CITY/STATE/ZIP ...:
SUNNYVALE, CA
94086
TELEPHONE ........:
(408)733-6360
FEE DESCRIPTION CNK
TOTAL
FEE
---------------
BREMACOVER
---
P
___-__---
14.43
BREMMISC
P
25.53
EPERMITFEE
P
35.52
MPERMITFEE
P
35.52
•111.00
VOICE ID
DESCRIPTION
........ ............................
303 ROUGH
MECHANICAL
505 FINAL
ELECTRICAL
•
PAID -TO -DATE
0.00
0.00
0.00
0.00
0.00
I:l2ngp[M>•Ulfa
14.43
25.53
35.52
35.52
111.00
VOICE ID DESCRIPTION
........ ............................
304 ROUGH ELECTRICAL
50B FINAL MECHANICAL