00010048 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-El ECTRICAL PERMIT NO
BUILDING DIVISION APPI.ICATIONIPERMIT
PLUMB NG S0001
BUILDING PROJECT IDENTIFICATION
BUILDINGADIIRESS: SANITARY NO. APPLICAIION SUBMI'17AL DAPI
la
/�
WNER' NAME?: PH( Ii: CO UR ]Ii:$NA ' LIC N f�
NIC CONTR(II,M
RCHITECT/ENG NEER: LM NO: ADDRESS: / ❑
CONTACT: PHONE: BUILDING PERMIT INFO
5/O2--
❑ CDnsultaf cc i y pp¢ant(Inhial) nEl El DMH, 1:1
LICENSED CONTRACTOR-'S DECLARATION QTy ELECTRIC PERMIT FEE
1 hereby notion that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
PCZ with Seeire V(hhllofDivisiin 3oflhe Husinessand Professions Codi my license is RESIDENTIAL,
LLT O p PERMIT ISSUANCE
CWF- InlirsoCeis Of.(. �s �� ❑$FOWL. KITCHEN REMODEL
F-Zw 4censc Class Lic.M��F-��y ppPL1ANCE5-RESIDENTIAL. ❑ADDITION ❑PLUMBING RE-PIPE
1 CQU Date ilii NNJIriVVV Comm -J �'
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
PANIO-S
MODIFICATION
ZOrn,Z., IunJera:md my pWns shall he used as nnhlic recoNs
02 , UP T0200 AMPS ❑INTI iRlOR DCHIM NEY RHPA IR
[-4~Yl Licensed Professional 201-100GAMPS IMPROVEMENT SWIMMING POOLS
SW= OWNER-BUILDER DECLARATION OVER H100AMPS El BATA REMODEUREPAIR [I DEMOLITION
W IY w Q I torehy affirm that 1 nm compo from the Cn.....Our's License Law far the
p U idlowing reason.(Section 7131.,Basions end Prnfesxions CteAny elty r coontY SIGNS d CHRICAI, ❑(YfHIiR
3 W h¢ which requires a Permit to construct,alter,improve,demolish or repair any uncture
�LL'O�l Prior as its issuance,also regaitns droopprcam forsnch Permit no file tod'neddoommem SPECIAL CIRCUIT/MISC.
ohm he is IicereeJ Pursuant m me provisions of the Cnmracmr's License Law(Chapter 9
ly p0 (nnnrmacing with S7tim70mhofDivision3 of the Easiness and Pmfwniors Code)or TEMP.MITER OR POLE INS'I'.
that he is conapt therefrom and the basis for the Nlcgcd cxempdnn.Any violnfmn of El NEW HLDG/ADDITION 0 DEMOLITION
_4• Scation]03LS by any epplicam fora Permit xubjemsthe appticannoa l penapy of POWER DEVICES
r� of more than five hundred dollars($5Wf, ❑'TENANT ❑FOOD SF:I2VICE
F�6I,as owner of the rt.or employees with woes as their sole cote tion, SWIMMING POOL ELECTRIC OTHER IMPROVEMENT
❑ Propc y Y P Y 8 penan
�an w dl Jothewon,unite: he Contcomeractor'ma,
License
].a.ducred butane apply.a. a13LLall Of GT111iR
is
m unit Professions Code:The Cnmmetor's License Law Jnes nm apply m en owner Of OUTIJi15-SWU'CHP.S-FIXTURES
6'w^ Property who bonds or improves thereon,and who does such work himself(it through
-75N
his own employees,provided that Such improvements art not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.if,however the building or Improvement issnld within one year of cempleion,the S l'.FLOOR AREA $/SQ.FT.
ownerbuilder will have the burden of proving that he did not build or improve I'or par,
,amoromeJ.
[3az I,au r of the Property ten xchaively rnmmaing with licensed contractors to 'I(yrAL:
mnhthe pntject(Sec.](144,Buslnna and Professions Gado)The Contnmmr'S Li-
cruse Low does not apply it)an owner ofpropmy who builds or improves thereon.and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a cormorants)licensed pursuant o the Contractor's
License law. PERMIT ISSUANCE.
❑ l an,exempt under Sec. ,13&PC famhis rwson
ALTER-DRAIN of VENT-WR'I'ER LA) VALI]A'IION
Date AF5�
WORKER'S COh1T'HNSATTON DECLARATION BACK FLOW PROTECT.DEVICE
I hereby al amt under penalty ofperjuty one of the following declarations:
❑ Ihave andwill for
naCeni 37111 of thm Labor
Code.
for Worker's Comp the DRAINS-FLOOR,BOOP,AREA.GOND. STORIES TYPE GONS'BHGI'IfIN
w k f as provided for by Secdou 3]1111 of the Lahnr Code,far Ore petiormunce mf the
work for which Ibis permit is issued. FIX'I'URI3-PER MAP
❑ 1 have and will de,for Workefs Compensation Insurance,us mquireJ by Seainn'
3700 of me Lubar ode.Innhe pert "to"ofthe work for which this promou is issued. GAS-❑A.SYSTEM-I INC.40UTLETS OCC GROUP APN
My Worker/� tensati',t Incur r' rant Policy o9aSy
Commit: a Poli Polite,yb*lomllGAS-EA,SYSTHM-OVER4(+A) 7
CERTIFICATE OF EXEMPIIDN FROM WORKERS'If/O
COMPENSATION INSURANCE V V GRHASMNDUS IU,WAS IT IN1 ERCE17OR
BUILDING DIVISION FREES
(Thlssmtitnnced not becoan,fical ifthe permit is furore hundred dollars;($Han GREASHTRAI'
or Ins.) PLANCI ILCK IT?I?
I realty that in the performance ofthe work liewhich this Permit is issued.I shall SEWER-SANI'T'ARY-STORM EA.2W 14,
not employ any person in any manner so as to become subjecuo the Worker,Coroner- ENERGY FEE
Zz Nation Laws of California.Dam WATER DRAPER WNENTIELECIR
Q Applicant ` GRAVING FEE
.N. NOTICE TO APPLICAME IL otfun nuking this Cenifirate of Exemption,you should WRIER SYSTEM/IREATING
a � becomesubjea to the Worker's Compensation provisions of the Labor Cede.you must SOILS FEE
{>a forthwith comply withsuch provisions or this permit shall be deemed revoked. WATER SERVICE
Flt Q
CONSTRUCt]ON LENDING AGENCY NEW RPSIDEN'tIAL PCMB. SQ.FI. PAID
,� Date Receipt#
V I ter
affirm that issamsauc.30G.lending agency limb¢perfiamtanw of
the work for which this permit is issue)(Sec.3119].Civ.C.)
V. F'' Lrdell Name "I U"fA 1.
L) :
Lcadeds Addrnes 'COTAh:
S1 certify aha I have read this application and some Nat the above information is BUILDING FEF:
N contact.Iagrw m comply with all city and rmm,urli......andstamlaxsmlaingto QTY, MECHANICAL PERMIT FEE
U ,ZZ. building conswdion.and hereby anthorire representatives of this city to enter upon the SEISMIC FEE
abuse mentioned profel,for inspection plan"r, PERMI''I.SSUANCH
fWe)ogre¢to cove,indemnify cad keep harmless the City ,I Cupertino against ELIiC'1'IiIC THE
liabilities,judgments.costs and expenses which nosy in any way accrue against said City ALTER OR ADD TO MECH.
in consequence of the gramid,of dais Noun. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINT AIR HANDLING UNIT(TO 14000CFM)
SOURCP,REGULATIONS MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000CPM) CONST RUCTION TAX
Signature of AppliOurfiContracmr Dau; EXHAUST FOOD(W/DUCO HOUSING MITIGATION FEL?
HAZARDOUS MAI HRIALS DISCLOSURE
Will the.,,Iicomor future huilding occuPam uorc or handle hazardousmaterial HEA'L'ING ON]'I'(TO 1110,0181 BTU)
as defined by the Clpenino Municipal Cade,Chapter 9.12,and the Health and Safety
Com.Section 25532m)? BEATING UNIT(OVER INE000 BTU)
❑Yes El No PAID --
VI?N'I'l1.AT10N FAN(SING hIi ItESID) Dara Rc7ipt#
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILI:R-COMP(3HPOR IOBOMBTU) TOTAL:
UiuricC'
❑Yn ❑Nn BOILER-COMP(OVER I00JIM BTU)
I have twit me hmardous materials"mramems under Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDE?N'UAL MECH. SQ.FP.
building docs not cuncatly have a umum.that it is my mrponsi itily m notify Ic ocenfumt
older on lir mems which most Fe met prior m issuance of a CertiMam of Ocntp:mcy.
Owner or authorized agent [)ate TOTAL: ISSUED BY:
OFFICE
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
BUILDING PERMIT INVOICE OPERATOR: christya
Sec: Twp: Rng: Sub: Elk: Lot:35709084.00
INVOICE DATE......: 01/11/2000
REFERENCE ID # ...: 00010048
SITE ADDRESS ..... : 10165 SCENIC BLVD
SUBDIVISION ...... .
CITY ............. : CUPERTINO
IMPACT AREA ...... .
OWNER ............ : PENINGTON KENNETH H ET AL
ADDRESS .......... :
CITY/STATE/ZIP ...: APO BE, 09021-0002
CONTRACTOR .......: GILROY, JOHN LIC # 15128
COMPANY ..........: JUST WATER HEATERS INC
ADDRESS ..........: 1764 NATIONAL AVE
CITY/STATE/ZIP ...: HAYWARD, CA 94545
TELEPHONE ... .....: (510)293-9901
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 --.. .- 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
•
I 1TRN.10.2000 10:48AM NETCLERK INC (10:897 P:30 —
CITY OF CUPERTINO
BUILDING PERMIT APPLICATION
103W Torre Ave. Cupertino,Co.95O14
(408)?77.9228
PROJECTADDRESS: 10100 amid Styd BLOC
at 8UITElAPT#.
PROPERTY OWNER CONTRACTOR
OWNERS NAME; CW,Mu,rmd NAME jug Wiwer Heaton Ino
MAILING ADORM.1016! SaNOld Q MAILINGAODR80g;
1704 NeOamel Aw
t:ITY/STATE/ZIP: C,Opahyq, 'CA 960t{ CITYWATMP, Hmeeerd
PHONE*( e08)e7Le8ee FAX* ( ) CA es0a0,1722
PHONBIk( 61 O)2SO.2012 FAX#; ( )
EMAILADDRc B�WDRE80:
• LAD
WrMd®Itlalwetedwafua,ne( .
BUSINBSSUCENSB* 1!120
SLAW WORK TO BE PWOFMM.- WAter Heater Replacement 50 Gallon Gee
-- I�CAANIGL:—� FWM8yN0; ✓
RBROOA EABARDOViFatE ARL YRS_ NO_- N(J►ffi8R OF0
8XL4IDs0 ROOF W V88ddG9:�
T1fP8 OF SXL71TeeD ACOP COVdRIId01
PSOPOSM SOoF COV8RM&
MAWROPmama ROOF COV9(Bi08R8govpt a
NUMS3ROPe] VMGAOOFCOVsiuW4R"AWBD: O
PR04TD8 LCJ).0.AMAT NO.
VALUATIav: 885.00__
• IMPORTANT NOTICES NOTICE TO APPLICANT
APPNCANrS CMIgCArM 1 Eby It@m wider PMft of PO4M ON at the aodmebmp dwiewsoM:
IAN OVE CERTIFY THAT I HAVE READ THIS APPLICATION AND aTATB THAT TH8 I ) t I lour e d ten malum n a oniticey dwnlatt m eesa ewe Ce .
SUEDFOR
RTHEDEMOLI CORREgRwisBB THIS
APPLICF A ATION.
owadoa,08"Idea ey So lea 770a dM tabor cam.M ae Palimeeee
SUED SIGNS O THE PERM
DESCRIED 18 THIS APPLICATION,ALLTHB of 11%soltwmm tiY pmelt b is,"
PROVISIONS OP THE PBRMR AND ALL,LAWS AND ORDINANCE
THERTO WILL BE COMPUBD WITH. Nr L w N"and%A ewingln a ftw"weapon OgImnoe,oo nqutydhy8o
dm 77M etdw Libor Cod■,for the W ft d%w of the wort for waft iNe
HOLD HARMLESS CLAUSE,The pemm2es(s)by eaeepbnoe of Sm an1IIL � �' my Wwww aemWm wwbn b a aenw oa111eI end p aq rle n
eproep)b Indamnpy and hold hoiden 0a CIV d CupMbw nom end Cemder Clarelldon
peink any end d claims,demands and ao11oM For dwapes howling hone
opium+sunder whisPemdtngardgttdneellpeniedtlwCiyelCupsNro ftbNumbr02N OD01018
galnstamsum daime,demon"orswam I ) M TM motdthe Vertdam meloeerIML
state
of mC*t0.Y rdtlr Tho Prodsla+ts d 8eedat 9800 oltha Lebo Code d1M t ) N I aAyew!M ease pMomwrmm ddme BerlclbrrWam whh pemtit 44aued.I
Blab dC.Ww' ,who spp*m shall haw oaW oFt under(O,or II
netad below a Ihwt hdlmio items(IIO,or(M,or(V),whkhaw to i ilooble. en main ampler any pares(in any mvnnv.e u m become wbrlaoc m rat.
Nhowswr tsen M 4 choked than lM must be aheeked asra0.Maw*dre unt inft o.�iraotia 1 ws u�k h ItlubJ 4 m the ,Mntatlmd
aFYropdam(Mead d eompllan4, preweme afar Labor Cade of Cel%%W and tan to comply t6nhwldm wdm
shW de rSoudon dd Mloked Jlago
Wddr 4barCade,mat dem WnrmeMNn apPeed lhr
NCWED CCM UCTORe 01CLAFATIO1
OIbA rMMenlnmdwmenesanrowinev app poanedrylpb bmM6ia�d f ) V. Ift*Ytleawe ordaacent Nrdme 061110)061110)dwt N ON FafbIrra oder
eeCemm leap!mroaiia+a MV•Oayeaq
walm hwNchavis Pommk ls taued.I Mu e�m�my,•mnoeeterwrw crap(
Lhenm 891929 C98 B 0S/3lama stet the sorkmrn'compenoten Iw d owlknie ere who.anor m aw cam•
etc mawmaldaV%alt we Ne•eemplemd mss a aL awn t die Centel
PAYMENT
Fen it 0uneu,
'
ACCOUNTS 7 / 7
BRPIRATtoN DATg O D
CRED87 CARD TYPE NAME ON CARD;
TORE:
Aim AMOUNT c
.ntrweae--tOL DEC 8 �oDD Scott Waterbu
OATS p"W Nrne 0,410 ltl
URN.1�0..R20000 10:49RM NETCLERK INC ('10:897 P:31
ITOt�p ,I O. : 6-60�UtIC1178 fOf t(10 Wo Oubuque�mnu
bwh sen /MaClaao, CA NoeO
saes)as CLERK
Buildina Permit . ..... ition
From: NetClerk Inc. To: Bnllding & Planning Department
CoaraetNewe. Seotx Waterbury ChIr Cupertino
Pbone: (650)6240426 Phone: (408)7773228
Fall Number: 1-(877)8464888 Fox Number: (408)777-3333
Permit Handling Instructions
Pkaao Fax Pernik tot I{877888 Dalieer to Job the at Drat hsapectiou
I will pick permit up at the BuOdina Department i4 5 aaya X Pkate mail to ContraMr address below
Othm p191114 Guid Pernik tot parmitt®nektarkmin
Contractor Information
Company: Just water Heater 1w. worker's Comp m 02KROOD1018
Contraetgrt Atte:Arnold State ContractoNt Cleanse ti $9I329 ClassC-36 B
Aaarws 1764 NationalAve,
Credit Card Information
Cur. FIa,7ww4 Ce.94545-1722 Credit Card Numbers $4744331-7168.6326
phone: 510293,2012 Name on Card: Just Waw Reatm Ina
xs SID-793-436D Up"U"Date. 09/02
° ParmiU iustwaterheatm slat Viae MarterCatd
Commentrt
Authorization forma:
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