00020003 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPE RTINO BUILDING-ELECTRICAL. P�ERMITNO. �s
IIUILDING DIVISION APPLICNFIONIFERMIT PLUMBING-MECHANICAL. ss�...�.-�.@I
BUILDING PROJECT IDENTIFICATION V '�T -it '�W
B�ON•AD OS ^ � S�ARY NO. A-SPPLICATION SUBMITTAL DATE
OW E 'S NA F' PHUNE\cif•^A.k�s-c?-6 6 IIA R'S NAME' � 1 C NO: � `
llgNAME'. NIC CONTROL
'HITEC'HENGINETR: LIC NO: A DRGS ❑
J S. `75 Z_
CONTACT: PHONE: I ' . BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ ❑
LICENSED that CONTRACTOR'S DECLARATION QTY, _ ELECTRIC PERMIT FEE
1 heresy amr.that I am Ea.,ed ander provisions of Chapter 9(enmmendng ]OA DESCRIPTION
O C Z Y RESIDENTIAL:
m sextan 910011 of Divl.inn3ofthe ltuviness and Pm[essinns Code,enAm license is ..
kms,W" wt PERMITISSUANCE
n full Trate and elle
aUZV Licarsc C}as Lica �� ❑SFDWI. (_1 KITCHEN REMODEL
tiG1 Unc • Commnnr APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
F,Pr/+ AIiCHIT'[Gr'S DECLARATION PAN13LS ❑MULTI-UNIT ❑STRUCTURAL
Z O to Z I understand my plans shall he used as public records MODIFICATION
h OZ- UP TO 200 AMPS 0� El INTERIOR ❑SWCHIMNEY MINGREPAIR
POOL
H[�..F.� Liccnud Pmlcssional 201-It]fN1AMRs IMPROVEMENT SWIMMING POOLS
yd W'J OWNER-BUILDER DECLARATIONOVER 1000 AMPS El BATF{REMODEWREPAIR ❑DEMOLITION
CC
W, I heresy affirm that I ammexempt from We Contractor's License Law for the
ad k Q fallowing micas.(Section 1031.5,Business and Professions Coda Any city or coumY SIGNS ELECTRICAL ❑OTHER eQ
which requires a permit to constru ,alma improve,demolish,or repair any,unetcm Q.�-[�
pria, issuance,alsonegnlres the upolseant foreuehpemalit,fleo,ignedsmtemen, SPEC1ALCIRCUITIMISC. ODU 16T141
�p. that he is licensedpursuanno the provisionsofthe Cmnrader's License law(Chapmr9 /
�q'OQ (emmnencingwim Section 7000dof Division 3 afthe Business and Professions Code)or TEMP.METBR OR POLE INST. COMMERCIAL
at c.c Ir' that he is exetpt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�`"y Section 1031.5 by any applicant n permit subjects the applicant m o civil penalty of POWER DEVICES
F,zy nut more man live bmndred dollaa 6500). ❑TENANT ❑FOOD SERVICE
f=OQ ❑I,as owner of the progeny.nr my empl�yeeswi,h wages astheirsolec�mpensation, SWIMMING POOL ELECTRIC OTHERIMPRO
will do the workRai,and the announce is not intended or offered for sale(Sec.J0A1,Business ❑ THER
9 and Professions Code:The Contra......License Law does not apply m ua owner of OUTLETS-SWITCHES-FIXTUN
pn.peny who hat Id,or Improves marc.,and who does such work him,elI...through
his own employees,provided that such improvements are not inmtded or offered for ISIiW RESIDENTIAL ELE?CTR SQ
sale.IL loan,the building or improvement is sold within one year ofcompletimific SQ.FL FLOOR AREA $/SQ.FT.
builder will have the harden of proving that he did not build or improve for pvr-
pse er-of sole.).
C] 1,as owner of the pmpeny,am exclusively contracting with licensed contractors to TOTAL;
compact the project(Sm.7044,Business and Professions GNe:)Tne Contmcro's L.i-
wbseLaw does not apply to an owner of progeny who builds or improves theater,and QTY, PLUMBING PERMIT FEE-
o contravis for such projects with it conlmefiaN licensed pursuant to me Coarse,.',
License Law. PERMIT ISSUANCE
❑ I am comp,under Sao ,B&P C f..r this manm
Owner Dee N.TER-DRAIN&VENT-WATER(EA) VALUATION
.41 WORKI?R'S COM P[NNSATION DECLARATION BACK FLOW PROTECT.DEVICE
I barely affirm under penalty of perjury ane of the following declarations:
❑ I have and will maintain a Certificate of Comwerto self-insure for Worker's Contain- DRAINS-FLUOR.ROOF AREA,COND. STORIES TYPE CONSTRUCTIONstint,a,provided fnr by Section 3900 of the Labor Code,far me perfornnnee of the
Vfnr whkh bis permit is Issued. FIXI URI?S-PER TRAP
have and will mimed
aoin Worker's Compensation Insurance,as orro by Section
W ofthe Lolaa ode. P haperfn ante af,he work for which this permit is issued. GAS-EA.SYSTEM-IINC.40IJILETS OCC.GROUP APN
MYWerke to pen- a s :are , i and Pal%ryyy pp��
Carrier: Policy No- Z- 51�t)4 L16 OAS-EA,SYSTEM-OVER 4TA)
CERTIII ATE OF EXEMPTION MOM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
(Thi.,union need not be completed if the permit is for one hundred dollars($110) BUILDING DIVISION FEES
nr less.) GREASE TRAP
I cenily that in the perfo..annnf Ne work far which this permit is issued,Ishall SEWER-SANITARY-STORM EA.200 FT. / r
not employ any person in any manner so as to bcmme subject m the Workers'Compen- ENERGY IEE
Z satin.Laws of California.Data I E
WNR 11 RATER W/VENTIELECTR ^�
Z O Applicant IRAI)ING FEE
'7" h
NOTICE in APPLICAN'P.If,after making this Cerlficate of Exemption,you should WATER SYSTEM,TPUL LNG V
a ? become subject to the Worker's Compensation provisions of the Labor Code,you must kGuEsI
B
457 forthwith comply with such pmvisions or this permit shall be deemed revoked. WATER SERVICE
is Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PURL SQ.PT AID
V O I hereby affirm that mere is a construction lending agency for the performance of v Data R.cipta
[L Hthe stock fnr which this permit is issued(Sec.3091,Civ.C.)
Lcnder'e Nun¢ - —rTYIrA
0 U Lander',AJdres 'TOTAL:
I certify mat 1 have mad this rptcatinim and station,the above information is BUILDING FEE
.F.t T4/) corzca.Iagrceut comply with all city unJ mumy nNinanca unJ sem laws relutingm QTY, MECHANICAL PERMIT FEE
oZ huilding constmaiom and hereby anthoom representatives of this city torntcrupon the SEISMIC FEE
above-mentioned progeny forinspect apurposes.
(We)agree m zavc,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liandities.jmdgments.mets and expenses which may in any way acerve against said City qI TER OR ADO TO MECH.
in....sequence of the granting or'his pemnlr. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI I(TO 10,1001 CFM)
SOURC '. ONS. / MECHANICALFEE
/ 00 AIR HANDLING ON['T(OVER 10,000 CFM) CONSTRUCTION TAX
Signature nl'Apphyri/Cnmmctm Ilam LXHAUS'I'Ht10D(WIDUCT) ` HOUSING MI'TIOATION FEF.
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hmN
aom
us medol HEATINGUNLTIT.I W,..TU
is defined by,he Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)'! I1EATING UNIT'(OVER 100,000 B-I U),
p Ye. E]No PAID
VENTILATION FAN(SINGLE RISILp Date Receipta
Will the air arm or furore building occupant use equipment.ArQm devices which
amlthuvanlrus air cnnwminune as Jellned by WC Be,Areu Air Quulily Management BOILER-COMP(3f{p OR lfXI,(Xgl BTI1)
UisnicB TOTAL:
pYn Fl No BOILER-COMP(OVER I00,0W BTI.
I have read the hmardous n o criaE majoen encs under Cha ter 69,5 nt the Culi- AIR CONDI PONER
4 p ISSUANCE:DATE
Banta Health&Safety Code,Sections 25505.255.33 and 25534.I understand mat if the NEW RESIDENTIAL.MECH. SQ.F-L .-a
building does not currently have a tenant.that iti.s my responsibility.notify the verepon, L
of the requiremems wNam hich must met prior issuance of Certificate(if Occupancy. C.--
Owner m awhmard ages Data T03'AI ISSUED BY:
OFFICE
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE, INVOICE INVOICE INVOICE
CITY OF CUPERTINO
• BUILDING PERMIT INVOICE OPERATOR: nancyc
Sec: Twp: Rng: Sub: Blk: LOG:35910001.00
INVOICE DATE......: 02/01/2000
REFERENCE ID # ...: 00020003
SITE ADDRESS .....: 20735 SCOFIELD DR
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: NEWMAN MARJORIE R AND WILLIAM
ADDRESS ..........:
CITY/STATE/ZIP ...: CUPERTINO CA, 95014-2962
CONTRACTOR .......: LEW SNAVELEY LIC # 21610
COMPANY ..........: DIAL ONE SERVICE CHAMPIONS
ADDRESS ..........: 430 REYNOLDS CIRCLE
CITY/STATE/ZIP ... : SAN JOSE, CA 95112
TELEPHONE ........: (405)452-1174
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
_______________ _-- ----- --- ------------ ____-__-___
BREMFURN P 12.21 0.00 12.21
MPERMITFEE P 35.52 0.00 35.52
_________ ____________ ___________
47.73 0.00 47.73
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
.. ........ ............................
ROUGH PLUMBING 303 ROUGH MECHANICAL
9 ROUGH ELECTRICAL 505 FINAL ELECTRICAL
507 FINAL PLUMBING 508 FINAL MECHANICAL
•