00010165 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY D OO '
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
POACHING DIVISION APPLICATION/PFRDIIT PLUMB INO-MECHANICAL C
BUILDING PROJECI'IDENTIF'ICATION J am
NUILDINGADDRESS: SANITARYNO. APPLICATION SUBMITTAL DATE
0��577 �n J030 Ad _ Z- 2oo o
OWNF.R'.S Nr A.ME:, / 'P _ NTRA TO 'S AMI:: LIC NO:
Cah/<��X•.II ,fa NIC CONTROL
Lf)RCHUMCT/ENGINEER: LIC NO: DR . ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Facts Paid by Applicant(Initial) BLDG EL,Cf PLUMB MECH
❑
LICENSED CONTRACTORS DECLARATION ❑ ❑ czQTY ELECTRIC PERMIT FEE
I notchy an;rm mm 1 am Ran,w adder pmvisiona nr Chapter 9 y license
JOB DESCRIPTION
O4'Z condo Section701p)or Divisinnlof the Business anJ Patteson sCwe.an ylicense is
ADO rERMITIsSUANCIi RESIDENTIAL:
FBF nfull force and eRect. _ ❑SFDWL E3 KITCHEN REMODEL
�UU LicenseC au Lic.p APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
F;W Dme Contract
ror
tt RCHITECT'S DECLARATION ❑MULTI-UNIT El STRUCTURAL
F D'n PANELS
I ord'olou i my phms shall he usul as public records MODIFICATION
OZ—, UPT021TAMPS El INTERIOR 11 CHIMNEY REPAIR
<�2f'; Licensed Professional 281-1000ANIPS IMPROVEMENT EJ SWIMMING POOLS
( c w st OWNER-BUILI31iR DECLARATION OVER I"AMPS ❑BATH REMODEL/REPAIR El DEMOLITION
C Q 1 hereby nffimo aha I am exempt from me Commando's License Law for the
L o.U following reason.(Section 7031,5,Business and Professions Code Any city or deeplySIGNS ELECTRICAL
❑OTHER
which requires n mi
pert o,conswet,alter,initials,demelieb,m repair any,mctme
.F.^� prior tons issuance.also requires the official l in suchpennit to file aei6nwsbaemenl SPECIAL CIRCUIT/MISC.
QE that he is loused ynrstimau,the provisions none contractors License Law lCnapter9
(comnmmingwith gradient 7000of Division 3 oftbe Bor,orseand Prold,samns Coded., '1HMR MET ER 014 POLHINST. COMMERCIAL:
that he is exempt therefrom and the basis for the alleged exemption.Any violation of NEW BLDG/ADDITION El DEMOLITION
^N Section 703ISbyany applicant fora permit suninatsthe applicant toe civil penaily of POWER DEVICES ❑TENA ❑FOOD SERVICE
F Z} net more Nan five hundred dollars(5500). IM EMENT
p=Q 01,as owner of the prnpeny,or my employees with wages as thei...1,compensation, SWIMMING POOL ELECTRIC Af
ER
will do the work,and the structure is not intended oroffered for sale(Sec.70,14,Business
1 m and Panfeselors Cndc',The Centracmr's License Law,does not apply It,an owner of OUTLETS-SWITCHES-FIXTURES
property who hull s or Improves thereon,and who does such work hinisclr or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FC
safe.If,however,the building or improvement is said within one year ofenmpladon,the SQ.FI'.FLOOR AREA VSQ.ET.
owee,hadder will have the bonder of proving that he did not build m improve far pvr-
poac of sale.).
1......er more'attic",am exclusively Contracting with licensed contractors to TOTAL:
Consumer the project(Sec.7014.Business and Professions Code:)The Contractor's Li- - -
whselawdoesnotapplyroanownerofprnpenywhobuildsorimprovesthereon,and QTY.' PLUMBING PERMIT, FEE
o ontmes forsuch projects with acontmcnn(s)Iipsawdpurxuar0o the Contractor's
Liaens Law. PERMIT ISSUANCEE] I am exemptundcr Sed. ,B&P C for this reason
Owner Dme ALTER-DRAIN&VENT-WATER UA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE ,0� )
I herebyiffrm under penalty or perjury one of the following declarations: vow l/LJ
[have and will maintain a Certificate el Consent to self-insure for Worker's Compel- DRAINS-FLOOR.ROOF,AREA,GOND. STORIES TYPE CONSTRUCTION
senior,as provided fat by Section 37M of are Lounr Cwe,for the if ounce of the
r for which ran permll is issued FIXI GRES-PER1RAI'
nave and will n unit..n Workers Cmnpen,anso Insurance,as rnlrired by Section
3700of the Luton Code,for the perfmmonceof the work for whi,h,bis permit is issues. GAS-EA.SYS TII_I INC.4 OUTLETS OCC.GROUP APN
Cy WorkerpQhphlyhyr}g[l>ranee carrier and Policy M
AYJr�/T Policy Na:LYC/f(1k Lam✓ GAS-EA.SYSTEh1.OVERi(EA) 00(�I
CF,RTIFICA'IT OF EXEMPTION FROM WORKERS' O/
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERCEMOR BUILDING DIVISION FEES
(This section new not be completed ifthe permit is foram hundred dollars($100) GREASE TRAP
or Ices) PLANCHECK FEE
I eenify shut l It doe porknmlmaeof the work fm which this permit i......it,Isholl SIiWLR-SANITTARV-STORM EA.20()17.not employ my person in any manner so as to become subJmt to the Workers'Comped- HN BRGY PER
Z smain Laws of California.Date / WATER HEATER WNENT/F,LECTR
Z Applicant GRADING FEE
fq NOTICE TO APPLICANT:If,after making this Canniest,of Exemption,you should WATER SYSTEM/1'RHATING a SOILS FEE; become subject to the Workers Compensation provisions of the Labor Cwe,you must
1,7.1 forthwith comply with such provisions or this permitshall he deemed revoked. WATER SERVICE
Q
CONS'RUCTIONis ac ONLENDING AGENCY NEW RESIDBNT'IAI.PhMB. SQ.IT. PAID
UQ hereby issued(Sec 30 lending agency fnnheped"ornwnee of Dom ReeeiptM
W H the work for which this iwmoit is issued ISec,3(197,Civ.C.)
Lenders Name TOTAL
O :
r LUL. Isnde Address TOTAL:
ry I certify Ins 1 have read this application and state that the above information is BUILDING FEE
Fy coat l agree to comply with all city and county ordinances and state laws relating to QTY: MECHANICAL PERMIT FEE
C) building construction,and hereby inanimate reprcsemaives otitis city tont upon the ' SEI S M I C FEE
ubove-merromed prnpeny for inspeedan pmpoouc PERMIT ISSUANCE(We)three o suvc,indemnify and keep harmless theCity tino of"Cuperagain. ELECTRIC EEE
Iinhilities,judgments.cnslamdexpenses whichmay many way ecemengalnnl paid City AIA HE OR ADD'IO MECH.
in amuquencc of the grunting of this permit. PLUMBING ME
APPLICANT IN ERSTANUSAND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
MECHANICAL DIE
SOURCE RI t TIONS.
y( _ �q AIR HANDLING ON]F(OVER I4000CFM) CONSTRUCTIONTAX
Signature ofA oplmetor � Date V EXHAUST HOOD IW/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant once or handle nnmrdnus marerinl I[BATING UNIT(,I'O IgkNX)BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Cwe,Section 25532(.)7am�''ggHEATING UNIT(OVER No,"BTU)
❑1-es AN.
VENTILATION PAN(SINGLE RPSID) PAID
Dam RccciptM
Will the applicant or forum building necuWnt use equipment or devices which BOILER (3HP OR 1110,000 BTU)
mit hnxaalcu.v air ainmm'a a as defines by the Bay Area Air Quality Management TOTAL:
7bm1dm,c1d,,
istrict!
❑Yet No BOILER-COMP(OVER 100.000 BTU)
I havedthe hasWnus mamrialo rttryimmena under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
ortes BeaWo afeay Code.Sections M505.25533 and 25534.1 understand that if are NEW RESIDENTIAL.MECI I. SQ.IT.
cvorcndy have a tenant.Nat it is my resprrvibilily ao notify the occupantf the req h uw 'chmasa he row prionoissuaoce nfaCenificamof Occupancy.wner or rem D or` TOTAL:
SSUED 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:34217084.00
INVOICE DATE......: 01/28/2000
REFERENCE ID M ...: 00010165
SITE ADDRESS ..... : 22577 SAN JUAN RD
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER . ...........: DHUEY MICHAEL J
ADDRESS ..........:
CITY/STATE/ZIP ... : CUPERTINO CA, CA 95014-3932
CONTRACTOR .......: WARREN, HENRY LIC # 20719
COMPANY .......... : ABSOLUTELY WATER HEATERS
ADDRESS ..........: 191 PADDON PL
CITY/STATE/ZIP ...: MARINA, CA 93933
TELEPHONE ........: (831)384-5133
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
V' ID .....-. DESCRIPTION -----.-. VOICE ID --- - - DESCRIPTION
.. ...... ..202--- --------
SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 302 TUB & OR SHOWER
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING