000101340
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY CL>o 10 1-3 4
CITY OF CUPERTINO BUILDING - F.LF.CI'RICAL
BUILDING DIVISION APPLICATIONMERMITPLUMBING-MECHANICAL
fiat{ ii NG PROJECT IDEN9'IFICATION'- tt
PERMIT NO.
(�
J
BUILOINGADDRESS:
/O /a8 S�e,-n
SANITARY NO.
APPLICATION SUBMITTAL DATE
ERS NAME; vey n P ONE>—
' +
COOR"NA F.: /�� LIC I/
N/C
ElCONTACT:
CON'IROLN
CHITECT/ENG ilt: .I O:
ADDRESS:^ cxett✓^ ^ � 60'/
6,1.(W CJ r//Ja�/�n-
PHONE:
❑ Consultant Fees Paid by Applicant (Initial)
r. 'BUILDING PERMIT INFO
BLDG ELECT PL�U�M(Ij M H
❑ ❑ CJ ❑
LICENSED CONTRACTORS DECLARATION
1 hereby P.f that I am Iiehe11J under provisions of Chaster 9 (commencinga,cs
withllfor n adefof0ivixinn 3gRheHusinoss and Profess' ns Code. and/1,liwnae is
effete, /v
infulle class
Liccmc Cless Lic.N
Da¢ Contractor
CHITECTS DECLARATION
I understand my plans shall be used as pull is ru sol
QTy ELECTRIC PERMIT' PEE
- v`
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWI. ❑KITCHEN REMODEL
❑ADDITION ❑PLUMBING RE -PIPE
❑MULTI -UNIT C3 STRUCTURAL
MODIFICATION
❑INTERIOR GCHIMNEY REPAIR
IMPROVEMENT [] SWIMMING POf11S
❑ BATH REMODEUREPAIR El DEMOLITION
C1 OTHER
PERM19'ISSUANCIi
APPLIANCES - RF.SIDF.NTIAL
PANELS
UPI'(1200AMPS
Licensed Prufeslo..I
OWNER -BUILDER DECLARATION Commences
1 hereby affirm that 1 am exempt from the ionsC License taw for the
following reason. (Semina ]'dons Business and . , Professions Code: Any city or county
which .(louse a permit rot nmesme6'he,di. improve, h m ata. or mpulr any swment
iewancgalmreto he lhcasionsotFor
tprior 1. it,hat he n, suchperm'lLicense Law (Chatter
that heir licensed pursuant 7 the provisionsof the eBusinss License law(ChaptcrY
m theelied i Business add Professions Code) or
(commencing he is iscrapth Section7")and the
that he is exempt therefrom and Ne hasis htr the allege) exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not inneflan five hundred dollars USN).
❑ 1,asowmr ofthe,mpcdy, army employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Cale: The Conuacloos License Law does not apply to an owner of
property, who builds or improves thereon, and who does such work himself or through
his own employees, provided Nat such improvements am not intended or offered (
sale, 11, however, the building or improvement is sold within oneyearoicompletion, the'
owneomilder will have the burden of proving that he did not build or improve for pur-
1 axe of sale.)
❑ I, as owner of the property, am exclusively comrucbn6 with lis nseJ m to
construct the project (Sec. 7044. Business and Professions Cede:)' a Cont came, I-
c sc law does not apply to an owner of property who builds nrlmp ,vu lb on,ad
who nmtmcte fnr such smjects with cam into s) licensed pursue a t the Ca'mem s
License law.
❑ 1 ten exempt under See. , B & P C r this reason
201-Id(X)AMPS
OVER fid( P5
SIGNS LLECTRICAL
SPECIALCIRCUI'1]MISC.
TEMP. METER OR IY)hE INST.
COMMERCIAL:
El NEW tlLpG/ADDITION ❑DEMOLITION '
El TENANT El FOOD SERVICE
IMPROVEMENT
❑ OTHER
PO ° EVICES
SWIMMI POOLELE IC
UFL :l S1 SWITCI S -FIXTURES
N W'IDENT I. PLEC'rR SQ IT.
SQ. FT. FLOOR AREA
$/SQ. FI�
TOTAL:
r .
QTY. PLUMBING PERMIT'' 'FEE,
I'
ikMIT ISSUANCE
ALTER - DRAIN & VENT- WATER EA)
Owner ate
VALUATION
WORKERS COMPENSATION DECLARA
I hereby afftrnt under penally of perjury one of the following alamti s
scion, as provided for by Section 3]N) of the Labor Code, for the perfo
I have and will maintain a Cenifimde fConwrtoscif insure fur Weyb,clion
abusewhich this permit is issued.
abuse and will mainwin Worker's Cangm¢sntian hommuce, as retain3]W ofthe labor Code, for the performance oftbe work for which this pe
My Work�om i I�yuycJ caniesof
PolPulseicaf?y
Cortise ((YYCC ' I(� CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSAIION INSURANCE
ddollurs ($IIXps'BUIL.DING
or less.)
I certify the in the perfomtanee of tote work for x0ichthis nolo ix issued,ish'll
not empiny any person in any manner so usmbecome subjects the Workers Compen-
sailor, Laws of California. Date
At fides rn
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF', AREA, GOND.
STORIES
OCC. GROUP
CTION
E�N
FIXTURES- PER TRAP
GAS-EA.SYSTI:M-IINC.40UTI.ITS
GAS- EA. SYSTEM OVER 4(EA)
GREASEYINDUS'I'It I. WASTE INIRECEPTOR(Misscctionnccdnothecompletalifthepemiiiisforonehtm
DIVI
GREASE TRAP
PLANCHECK FEE
SEWER -SANITARY -STORM P.A.2gIfT.
ENERGY PEE
WA'1'lilt I (EATER W/V ENTNLEC'I'R
GRADING FEE
NOTICE TO APPLICANT: IL after making his Cere nr c of Exemption, you should
bcmme subjcm m the Wolds Compensation pmvisin of the Umor Code, you must
forthwith comply with such provisions onhis permit. allbedeemcdeasoked.
CONSTRUCTIONLF.NDI AGENCY
I hereby affirm that there isonmstmetion rating agency for the performance of
the work for which chis permit is Issued IScc.3 7, Civ. C.)
Under', Name
WATER SYSTENVIRFATING
SOILS FEE
WATER SERVICE
PAID
Dare Receipt#
NEW RESIDENTIAL PLMR. SQ. 14.
TOTAL:
Lendse, Address
TOTAL:
BUILDING FEE
I aem y that 1 have read this appli tion and state that the above information is
cat. I agree m comply wnh vn ciry a (amity oo iam ces and state laws relating m
building construction, and hereby umho reaepcowrdmlvcs ofthisciiy roster upon the
abovcmemioned property far aspiration purynses.
agree to save, indemnify and keep harmless the City of Cupertino against
liahilitics,jud6ments, cosu and espenus whichmayin any way'ants agamotmid City
mscyucnce of the grunting of this permit.
APPLICANT N ERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Sol !RE 1 TIONS.
! II B/- ii
Signmoreof Ap is nmr..or Date I/(/
l_ APARDOUS MATERIALS DISCLOSURE
Willtheapplictin mfmure huildingoerepont store or handle beenalms mmeriul
as defined by the Caliendo Municipal Code. Chapter 9. 12, add the Health and Safety
Code, Section 255321sT)?
yes o
Will the applicant in (antro building occupant use equipment or devices which
rdo
emit hesuus air contaminates an, def mrd by the Buy Area Air Quality Management
District?
E) Y,, IPINo
(`o+
1 alth read the haxardoas matuhJ5 5, 25ementa under Chapter h.l. of de Cali-
fomia Heo , S sty Code. nations 255x5, 25533 and 25534. I t onotify th Nat if the
builJingdm t rrently have snook that it is my resrymsibilirymnotify the occupant
of No to wd t be met prior to ismmor of o Certificate of Qcopancy.
I Da .B
- �,
QTY. MECHANICAL. PERMIT FEE
.t
SEISMIC FEE
PERMIT ISSUANCE(We)
ELECTRIC FEE
AL'I17R OR ADD TO MI'.CH,
PLUMBING FEE
AIH HANDLING UNIT (TO 10.000 CFM)
MECHANICAL FEE
AIR HANDLING UNIT (OVER 10d" CFM)
CONSTRUCTION TAX
EXHAUS9'HOOD (W/DUC)
HOUSING MITIGATION FEE
FENTING UNIT (TO I(hy" BTU)
HEM [NO UNIT (OV RR 100,000 BTU)
PAID _
Date Receipt#
VENI'lLA'TION PANIS] NOLE I2P.SIU)
BOILER - CONI' (3HP OR 100,000 BTU)
�
TOTAL: 'J -S
BOILIiR- COMP(OVER I(hS,(%q BTU)
AIH CONDITIONER
ISSUANCE DATE,
ISSUED BY: ✓O e YJIt�77. scar
NEW RISIDENI'1A1. MECH. SQ. FT.
TOTAL:
Ov,ncrorarMPod,k4d Dam
OFFICE
880 Dubuque Avenue
NetClerk, Inc.: e -solutions for the contracting industry South San Francisco, CA 94080
(888) 88 CLERK
I
Building Permit Application
•
'From: NetClerk Inc. To: Building & Planning Department
Contact Name: Scott Waterbury City: Cupertino
Phone: (650)624-0426 Phone: (408)777-3228
Fax Number: 1-(877)846-5888 Fax Number: (408) 777-3333
Permit Handling Instructions
Please Fax Permit to: 1-(877)846-5888
1 will pick permit up at the Building Department in 5 days
Other:
Company: Hot Water Inc.
Contractor:
Address: 2531 Graceland
City:
San Carlos, Ca. 94070
Phone:
650-298-8494
Fax:
650-298-8493
Email:
4246-3115-0117-2578
Comments:
Fax
Authorization forms:
Deliver to job site at first inspection
Please mail original to Contractor address below
Contractor Information
2. "Agent Aulhorizaaon"- By completing and nluming the information below,
you authorize Net Clerk, Inc. to not as an agent on your behalf
To Whom It May Concern:
Let this letter authorize NetClerk, Inc. and all currently employed and
authorized associates of NetClerk, Inc. to act as an agent on our behalf—
signingfor any and all building perm(ls and licenses required by our
company.
Sincerely, /'k r.241, .
Name: Ch.:s 6,,.s la,
Title: ;KS
Comapany: A4 In/cAA , V r, c -
Worker's Comp #:
1548386 State Fund
State Contractor's License #
763612 C36
Credit Card
Information
Credit Card Number:
4246-3115-0117-2578
Name on Card:
Chris P. Guslani
Expiration Date: 06/00
Visa n MasterCard
Credit Card Authorization
Company Name:
Company Address:
Phone: 6
Fax: . a 1
Email �. a mom...
Type of Card: /visa MasterCard
]Cardholders Name:✓re-g//SO
>Credit Card #: ,(rCAi/ ujlane Expiration Date. li ae
By signing below, I give NetClerk, Inc. and all currently employed and authorized
associates of NetClerk to sign credit card authorizations for the purpose of permit
applications.
!'n.;16usme
Contractor's Name Sigmatism Date
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
• BUILDING PERMIT INVOICE OPERATOR: christy8
Sec: Twp: Rng: Sub: Blk: Lot:37512009.00
INVOICE DATE......: 01/28/2000
REFERENCE IO k ...: 00010134
SITE ADDRESS .....: 10128 STERN AVENUE
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: DERHUEY FAN
ADDRESS ..........:
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
CONTRACTOR .......: GUSLANI, CHRIS LIC N 21311
COMPANY ..........: HOT WATER INC
ADDRESS ..........: 2531 GRACELAND AVE
CITY/STATE/ZIP ...: SAN CARLOS, CA 94070
TELEPHONE ........: (650)298-8494
FEE DESCRIPTION CHK TOTAL FEE
--------------- ------------
BPWHEATER P 9.99
PPERMITFEE P 35.52
45.51
VOICE IO DESCRIPTION
.. ............................
6 SEWER & WATER
301 ROUGH PLUMBING
502 FINAL PLUMBING ENERGY
507 FINAL PLUMBING
PAID -TO -DATE BALANCE DUE
------------ -----------
0.00 9.99
0.00 35.52
------------ -----------
0.00 45,51
VOICE IO ........DESCRIPTION
........ .................
202 UNDERFLOOR PLUMBING
302 TUB & OR SHOWER
506 GAS TEST