99090105 APPLICrANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
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CITY DI CUPVISION BUII,B NO-MECH UCALMECHANICAL PERMITPERMITNO,
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BUILDING DIVISION APPLICATION/PERMIT PLUMB OJECI'11)EWIFIC
i �'ItU1LDINf.1'R(kJECT IDEM'IFICA'L'[ON•-h'BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
0 A E: S Z f
` OW NAME: PHONE: CO RAC'TOIi'S NA E: LIC NO: Y
N/C CON']ROLOf
IRNP.R'RCHITECT/F. GINEER: LIC NO. ADDRESS: s '-? ❑
CONTACT: PHONE: ,I 4Y1 : ' BUILDING PERMIT INFO
DCT/l / /�Q A ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
S /CJ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION Q•ry ELECTRIC,'PERMIT FEF.
I hereby m)irm that I an.Brensad under provisions of Chuml,9 mmnlnencing - , . JOB DESCRIPTION
,0CMZZ with Section]0U(1)of Division Sof the Bmmr,, nd Professions CrCa'�l,vnd my licenseesRWIDENTIA
II--w. in full force and effect. /,Tty PERMIT ISSUANCE FDWI
�U U L,cen,• Lic.N TT G 2 fTCHEN REMODEL
P zaj Dan. Can'. a1Z APPLIANCES-kESIDF.NT1Ai, []ADDITION ❑PLUMBING Rl;.1'IP8
ARCHI'TECT'S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
F 7 N PANELS
z0'mz l understand my plans shall be used as public records MODIFICATION
O z=—a UP102MAMPS ❑INTERIOR El CHIMNEY REPAIR
[. W Licensed Professional 201-IWBAMPS IMPROVEMENT []SWIMMINGPOOIS
that
a -Ie U1LDER D'dif,C AI idacu OVER 10)(1 AMPS ❑BATH REMQgEl./J{EPAIR L1 DEMOLITION
1 hereby nflitm that 1 am exempt from the L'onlmmar,License law fonhc aUX•T/
46x13 a.U follon'ing rearm.(Section]031.5.Bms ness and Pmfese a Gsde: o an ❑OTHER
F. O m which requires a permit to compact,alter,improve,demolish,or n to
p p,i iF t......c..1 ouporee(oe apPlicam(or each Permit In fl sign t 1 me A I /
'p^�${�g that he is lixnsWpm.uammtbepmviaiuna nl'the Canuvemr's Lice CI
�p70O (commencing with Section 7000),f Division 3 olthe Busine,sand Profession,Codelm TEMP.METER OR POLE DIST. COMMERCIAL:
a a e C that he is exempt therefrom and the basis for the alleged cxcmph n.An la'to ❑NEW BI.DG/ADDITION []DEMOLITION
x�4 Section]031.5 by any applicant fora penna i,ol jtats the applicant m a ce pena i E S
Warn OIENANT ❑FOOD SERVICE.
yy not mare then five hundred dolhas(5cam,l IMPROVEMENT
❑xQ 01,uv�wneral the propeny,ar my employee,with wa8m,na thelrcolor, t >(
FSO will dothessork,and the shunure is not intended or offered for,ale(Sce.I(1M.Buslnes, OTHER
a 3 m and Professions Code:"a Contractors License law dad,nm o 1.7 s 'r
propeny who builds or improves thereon,and who does such wn
his own employee.,providW thea such impnrvcnents nm oat In RP E 'I I Q
snle.IL however,the bnilJingnr lntprovemeatie sold within o:,, ffc r Q.PI'.FLOOR AREA $ISQ,FI'.
a -builder will have the burden of prov'ng that he did not build m impmve for par `/
pose,d sown, /�Y_•t/J�/
1,as owner of the propeny,atm exclusively contracting with licensed contractors m TOTAL:
conx0uct the project(See 7044,Booiuess and PmficssimdS Cnde)The Cnnvnctar's Li- ,� - -- I
cense law does not apply to an owner of propeny who builds or Improves dramon,and QTY. PLUMBRVGPERMIT FEE °
who contracts for such projects with a commelops)licensed pursuant to the Contractors -
Licenselaw. PERMIT ISSUANCE `/ C
❑ I am exempt under Sec. ,B&P C for this reason 7
Date ALTER-DRAIN&VENT-WATER(EA) ALUA'HON
WORKER:,COMPENSATION DECLARATION BACK ROW PROTEGE DEVICE
I hereby vf0rte under penalty of perjury one of the following declarations:
,have and will muinmina Cenificate of Conserv to selGinsnre for Workers Compete DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONS iRUCTION
,anon,m provided for by Ser,lon 3700 of the Labor Gude,far the peifmntunce of tl o
work for which this permit is issued. FIXTURES-PERT RAP
❑ I have and will maintain Workers Compensation Insurance,as required by Section
39N1 of the labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP / AP
My WurkedkCom ,tion ,unmw careerola Policy mm� (P
G,rtlen,�'- /ter Palley Nn: OA9-I:A.3YS'fIiM-OVER 4(EA) -I,p 9
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR BOil.DN IVISION LEES
(This section need not be annpiead if the permit is for one hundred dollars ISIBuy GREASETRAP
or less.) -P ANCfiP.CKF 6
Ic mify louin lo,arformmeeeofthewmrk lorwhichtM1lapermil is iaued,Isha11 SEWER-SANI'T'ARY-STORM PA.20017. r
not employ any person in any manner so subject as to become subjeco the Workers'Compete 6F'))CY IgiE
ZZsatirm Laws of California.Date WAIER HEATHS W/VENT/ELECTR r
0 Applicant ' 1 GRADIN FE
y NOTICE'TO APPLICANT.11,after making this Conificate of Bxcmptian,yon should WAI'13R SYSTP.M/IRI7ATING lid) 'nIL ,FES
become subject,a the Worked,Compensation provisions ol'the Labor Code,you muss
fonhwi,h comply with tech provisions or Wis permit shall be deemW revoked. WAIER SERVICE
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMIL SQ,FT. PAID
V z I hereby olfannhaDhem is a construction leading agena,for the lwdiatuance of
w+ thewnrk for which this panni,is issued(See.NN7,Civ.C.) ��--,-_.--
LL U Lender's Name TOTAL:
U Lenders Address TOTAL:
r I renify that I have read this applic:ninn and state that the above inform Ginn is BUILDING FEE
coma,,[agree,,comply with all aityuwalyord;naace,and,tmamw,remtil,gm QTY,' MECHANICAL PERMIT FEE
C.1 z hu'ddina construction,and hereby authorize representative.ofthis city to enter upon the SIiISMICFEE
abrvo(Wei agrepropeny for inranily a keep es PERMIT ISSUANCE.
(We)agree to save,indemnify pd keep harmless the City of Cupertino against ELECTRIC FEE
�Ir Iivhilities,juAgmems.rusts and ex cosec which may in any way uceme aguinr said City pla'EIt OR ADD'10 MPRH.
in mneeyuonce of,he groping t Is permit. PLUMBING FF.P,
APPLIC UN1 FA S ND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO,00OCFM7
SOURG/P. UI ONS. MECHANICAL FEE
i AIR HANDLING UNIT(OVE.R 10.000CFM) CONSTRUCTION TAX
SBiI not ApplicanVC nwetor hate EXIIAUSTHOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOU ATI' IALS DISCLOSURE
Will theapplicarromfumm midi oacupam Wore nr hanAlehuaNnus material HEATING UNIT CTO 100.000 BTU)
vs dctinal by the Cupertino Manic al ode,Chaprer 9.12,anA the Heahh end Safety
CaAc,Section 25532(a)R HEATING UNIT(OVER 100,000 BTU)
❑Yes F1 No V17NI'I LXNON PAN(SINGLE RESID) PAID -'
Dam Receipt B
Will the applicant or future building by the B use equipment or devices which BOILER-COMPOHPOR 100,000 BTU)
.mit hmmdaus air contaminants as defined by the Bay Arco Air Quality Management TOTAL
Di,vicl'!
❑Yes ON. � BOILER-COM P(OVER 10(01 Q)B'I'U)
I have read the hazalloa,my is requimmems under Chapter 6.95 oIthe Cali AIR CONDITIONER ISSUANCE DAT
forms Health Safety Code,Sect' s 505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.17.I.,
7.
huilding a olcurnt haven tit is myrespamihllhymnotify thencapam �' /
of
na eofa Ccnifica¢of(kcupancy.
O Jagentnu Dam TOTAL: ISSUED BY:
OFFICE
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
• BUILDING PERMIT INVOICE OPERATOR: christya
Sec: Twp: Rug: Sub; Blk: Lot:36932048.00
INVOICE DATE......: 09/15/1999
REFERENCE ID # ...: 99090105
SITE ADDRESS .....: 20182 RODRIGUES AV
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA ....
OWNER . . ..........: FONG
ADDRESS .. . . . . . . . . :
CITY/STATE/ZIP ... : CUPERTINO CA, CA 95014-3100
CONTRACTOR .......: RODRIQUEZ, GARY LIC # 20940
COMPANY ..........: A AND Z KITCHEN AND BATH
ADDRESS ..........: 1775 S. FIRST ST
CITY/STATE/ZIP ...: SAN JOSE, CA 95112 `
TELEPHONE ........: 4087951190
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- --- --------- ------------ -----------
BPGAS P 4.44 0.00 4.44
BPLBGFEE 35.52 0.00 35.52
--------- ------------ -----------
39.96 0.00 39.96
t�ID -•----- -DESCRIPTION------ VOICE ID DESCRIPTION
.............. ........ ............................
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 302 TUB & OR SHOWER
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
7/
•
CITY OF CUPERTINO
I 1 of 1 BUILDING PERMIT RECEIPT OPERATOR: christya
COPY 1
Sec: Twp: Rug: Sub: Blk: Lot:36932048.00
DATE ISSUED.......: 09/15/1999
RECEIPT #.. .. ..... : 10083
REFERENCE ID # ... : 99090105
SITE ADDRESS . . .. .: 20182 RODRIGUES AV
SUBDIVISION . . . ... .
CITY CUPERTINO
IMPACT AREA ...... .
OWNER ............: FONG
ADDRESS ..........:
CITY/STATE/ZIP ... : CUPERTINO CA, CA 95014-3100
RECEIVED FROM ....: TIM
CONTRACTOR .......: RODRIQUEZ, GARY LIC # 20940
COMPANY ..........: A AND Z KITCHEN AND BATH
ADDRESS ..........: 1775 S. FIRST ST
CITY/STATE/ZIP ...: SAN JOSE, CA 95112
TELEPHONE .. . ..... : 4087951190
FEE IO UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW PAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
EPGAS OULETS 1.00 4.44 0.00 4.44 0.00
BFEE FLAT RATE 1.00 35.52 0.00 0.00 35.52
T PERMIT 39.96 0.00 4.44 35.52
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
CHECK 4.44 99090105
TOTAL RECEIPT a 4.44
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
__em.naa __saw= »-s-a=-m®ee----- =aa _seva��a�emz_�m��mee_nsa
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 302 TM & OR SHOWER
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
•
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
BUILDING PERMIT INVOICE OPERATOR: christya
Sec: Twp: Rng: Sub: Blk: Lot:36932048.00
INVOICE DATE. . ....: 09/15/1999
REFERENCE ID # ... : 99090105
SITE ADDRESS .....: 20182 RODRIGUES AV
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: FONG
ADDRESS ..........:
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-3100
CONTRACTOR .......: LIC N
COMPANY ..........:
ADDRESS ..........:
CITY/STATE/ZIP .... ,
TELEPHONE . . . .. ... :
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- --- --------- ------------ -----------
BPGAS P 4.44 0.00 4.44
BPLBGFEE 35.52 0.00 35.52
39 96 0.00 39.96
V ID --.- =DESCRIPTION--....--- VOICE ID SSSS-- DESCRIPTION
.. ..... ........ ...............
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 302 TUB & OR SHOWER
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING