00010029 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY to O O 10 0-.-
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. SOOOI
BUILDING PR(1,IE(T IDENTIFICATION
BUILDING ADDRESS SANITARY NO. APPLICATION SUBMITTAL DATE
/o i/K :✓ N ��� —fin. z
OWNER'S NAME a PIIuoo: COM' ACIOR'SNAME 0 LIC NO:
NIC COMIROLp
CHITECT/L•NGINF.ER: LIC NO: DDDR SS' '� ��n ❑
cDNTncr: PPiorve {�g� BUILDING PERMIT INFO
S�off- �.o?�e [e� 3 Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
D ❑ ❑ f5� ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm da 1 am licensed under previsions of Chapter 9(commencing JOE DESCRIPTION
QOO with Sectinn](NXO of Divisinn3of the Business lend lrolessions Calk.lend mylicenae iv PERMIT ISSUANCE
Fly in full fnrccondcR ^/ SFDWL ❑KITCHEN REMODEL
aUU LlcenseC ass LIL.X APPLIANCE —BESIDE ❑ADDITION [I PLUMBING RH-PIPE
F Z lq Dmc CnmmcOor
NQ6 ARCHITECTS DECLARATION ❑MULTI-UNIT ❑S'rRUCFURAL
ZOyZ' I undenstundmy plans shall butocil public records PANELS MODIFICATION
O ZN-''b UPTO200AMPS [I INTERIOR [I CHIMNEY REPAIR
C4CW Licensed Pmfcsamoul 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
C '� OWNER-BUILDER DECLARATION
w u I hereby a0irm that I am exempt(real the Commences License Low for the OVER 1!100 AMPS ❑B/pTH RFb10DEl/REPAIR (]DEMOLITION
iqqi55 d U follawiny moon.(Samun 7031.5,Rosiness and Professions Com:Any city or county SIGNS ELECTRICAL
INUI'HF.R ��XX
n+3 LL y which requites a permit to construct.she,improve,demolish,of repair aty someone ftA'/ A
prior on its issuance,also requires me applicant for such permit To file a signed statement SPEC1ALCIRCUR/MISC.
vWvW��} that he is licensed pursuant to the provisions of the Cnntnichos License Law(Chapter 9
eCp� (commencing with Section]00()of Division 3 of the Business end Professions Code)or TEMP.METER OR POLL INST COM 1
d y e p1 the he is exempt eacofrnm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
I+XI LL
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES [I TENANT ❑FOOD SERVICE
ZDw not more than five handled dollars($501). IMPROVEMENT
❑ has owner of the prupcny,nr my anpinyecs with wages as their sole compensation. SWIMMINCPOOLELECTRIC
at will do the work,and the structustructustructure,isnot intended oroffereJ for sale(Sm.n)tq Business [I OTHER
63 m and Professions Code:The Contmctor's Liceme Law does not apply ,,ret owner of GO rLE TS-SWITCIILS-FIXTURES
Property who builds or improves thereon,and who does such work himself m through
his own employees,provided diet such improvements arc not intended or offered for NEW RHSI DEN]tAL G6ECTR SQ EL.
sale.IL however,the building or impruvemem is sold within one yearido rmclu ,the SQ.FT.FLOOR AREA S/SQ.ET.
owner-builder will have the burden of proving that he did not build or improve for pur.
poor of sale.).
1,as r of the property,am exclusively commaing with IimnuJ ronuacmrs m TOTAL:
wtroOdum the prnjecd(Sec.]IW4,Business and Professions CNet The Conlmdors Li-
whocl.nwdtsfors applyman with
ofpmpcny who molds..improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects wiJu a commcmr(y licensed pursuant in the Contractors
Umme Law. / PERMIT ISSUANCE.
E] I am exempt under Sec, ,B&P C fonhis recon
ALTER-DRAIN&VENT-WATER(EAI VALUATION
Date
mer WORKER'S COMPENSATION DECLARATION BACK FLOW PR(TI'ECT,DEVICE
1 belehy ufMn under pemdtie of pe jury one of the following deductions:
Ihavc and will main by a imm37a¢of the Later Code,for the Worker's Cooper-
the DRAINS-FLDOR,ROOF AREA,COND. STORIES I'YI'F.CONS'TRUCT'ION
smirk,us provided for by Sadler 3]110 of the Labor Gavle,for penbrmance of the
walk for which this permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maim m Worker's Com oration Insurance,as required by Section
My .f e' esti perfor arta of(hawork for which this p.if u issued GAS-EA.SYSTEM-I INC.4 OUTl.GTS OCC.GROUP APS
My
T,ntwrCod for the
urencc 'cr and Policy �-s �nu �yr+j
Currier. Policy Nn.: la a? GAS-FA.SYSTEM-OVER 4(I:A) Js13 04V
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASIVINDUSTRL.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION IIEF;S
fUtisseaionneal not he comn
plded if the pandit is forme hundred dollars IS 10d) GREASETRAP
or l.") PLANCHECK FEE
maify(but in the FamnnancenDhe work forwhich this pennir is issued,l shall SEWER-SANITARY-STORM F.A.200 FT.
not employ any paten in any manner so as m become subject the Workers Compen- ENERGY TEG
0 Z sation Laws of California.Date / WATER HEATER WNENP/ELEM R
z 12 Applicant I GRADING PB6
t NOTICE TO APPLICANT:If.after making this CeniBcnre of Exemption,you should WATER SY$'rENIGREATING
F+ 5 become subject In the Worker's Compensation provisions of the Labor Code,you most SOILS FEE
{a Q forthwith comply with such provisions or this permit shall he deemed revoked WATI7R SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDIiNTIAL PLMH, SQ.FT. PAID
V 0 Ihereby affirm thatthem is a construction lending agency for due performance of Dale ReceiptX
tti the work for which this permit is Issued(Sac.3097,Civ.CJ TOTAL.
ULadre,Name
Lkl Lender's Address TOTAL:
Pn I cendy that 1 have read this application aud.smto that the above information is BUILDING FEE
o-F.h cmem.l agree..comply with all city and county adinances indstaelawsmlaingto QTY. MECHANICAL.PERMIT FE
V building construction,and hereby oulhoIre represenmtivesof this city to enter.,,.the SEISMIC THE
above-mentioned property for inspafion purposes. PERMIT ISSUANCE
(We)agree mt
to save,indemnify and keep haless die City of Cupertino against ELECTRIC FEEishilib ,judgmenu,costs and expenses whichmay in any waymcom.gainetsaid City ALTER OR ADD TO MECH.
in mns natio ,of the gmnding of this permit. PLUMBING TEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONd'OIMAIR HANDLING UNI'1'(TO I0,010CFM) MECHANICAL PEE
SOURCE REGULATIONS.
AIR HANDLING UNIT'(OVER 111,0111 CFM) CONSTRUCTION TAX
Signature of ApplicanUCnntmetor Date EXHAUST FOOD(W/DUC) HOUSING M ITIGAI[ON THE
HAZARDOUS MATERIALS DISCLOSURE
Will dheeffiicant mfmure building occupant store nr handle haxarJous..aerial HEATING ON]f('10100,000 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Sauna 25532(a)? ((EATING UNIT(OVER Idyll BTU) -
[3 Yes ❑NoVGN'I'ILATION PAN(SINGLE 1113SID) PAIL)
Date Remoth#
Will the applicant or future building occapam use equipment or devices which BOILER—COMP(3HP OR 1IXk0110 BTU)
connotations mrood is air conmu as defined by the Bay Arca Air Quality Management TOTAL:
District? BOILER-COMP(OVER 101.000 BTIO
❑Yes ❑No
I have read the hamNousmamrials mryicamats under Chapter 6.95 of the Cali- AIR CONDITIONER //ISSUANCE DATE
/�
Ionia Heath&Safety CNe,Sections 25505,25533 real1 understand that if the NEW RESIDENTIAL MECH. SQ.Fr. Iv L6 0 C2
building tines not cuncmly hove a tenant,that itis my rceponxibility nt notify the tcatpont /
of the amodravents which must be met prior to issuance of a Cenitca a of Occupancy.
Owner or:mdlamieed agent Date TOTAL- ISSUED BY:
OFFICE
JRN.10.2000 10f12AM NETCLERK INC NO.893 P.16
CITY OF CUPERTINO
BUILDING PERMIT APPLICATION
10300 Torre Ave. Cupertino,Ce. 98014
(408)777-3228
PROJECT ADDRESS:10833 WILKINSON AVE BLDG# SUITE/APT#
PROPERTY OWNER CONTRACTOR
OWNERS NAME: FRED HOLMS I NAME WATER HEATERS ONLY,INC.
MAILING AODR'98:10833 WILKINSON AVE MAILING ADDRESS: 970 E.MAIN ST.#200
S:ITY/STATE2IP: CUPERTIND CA 98014 CITYISTATEIZIP: GRASS VALLEY CA 98948
PHONE#:( 408) 253-0869 PAX#: ( ) PHONE*.( 1800833.4572 PAX 0-- ( 839274.3088
E-MAIL ADDRESS: E-MAIL ADDRESS:H2OHTRONLY®AOL.COM
_. BUSINESS LICENSE#:
EXPLAIN WORK TO BE PERFORMED: WATER HEATER REPLACEMENT
BUMMING; ELECTRICAL: b&SCHANICAL: PLUbMiNe .
RRROOF: HAZARDOUS PIKE AREA: YES— NO_ NUMBRR OF EXISTING ROOF Cl 0
TYPE OF EXISTING ROOF COVERING; PROPOSED ROOF COVERING:
NUMBER OF WU MG ROOF COVERINGS REMOVED; 0
NUMISEIZ OF RIMING ROOF COVERINGS MADW, 0
PROVIDE W.B.O.REPORT N0, VALUATION; 0.00
IMPORTANT NOTICES NOTICE TO APPLICANT
APPLICANTS CERTIFICATION I hereby affirm under penalty Of perjury one of the following declarations:
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE t I L I hew and will maintain a aarlifloete M consent to self4mm for waken'cont•
ABOVE INFORMATION IS CORRECT.I AGREE THAT IF A PERMIT 18 IS. Pemeticn.ere provided by Section 3700 of the Labor Code,for the perbmmnce
SUED FOR THE DEMOLITION DESCRIED 19 THIS APPLICATION,ALL THE of the wdrkwhiah rhle permit is Issued.
PROVISIONS OF THE PERMIT AND ALL LAWS AND ORDINANCES (y a I haw and win maintain worlam'companssaon Insurance,ea n0ubed by Sea
THERTO WILL BE COMPLIED WITH, son 3700 or the Leber Code,ha the performance of ea work for which this
HOLD HARMLESS CLAUSE.Thsparmitee(a)by acceptance Of the Duk. permit to Issued. My harken'ocmperaedon uaurance artier and policy num•
wrap: STATE FUND
a9ree(s)to Indemnify and hold harmless the City of Cupertino from and Corder
against any and all Claime,demands and actions for damages resulting from Polity Number 1518266
operations under this permit,regardless of negligence of the City of Cupertino
against all such claims,demands or actions. ( ) Is The dost or tee won done r stoo or lsee.
In conformity with the DMASlene of Section 3800 of the Labor Code of the l : M I aentfy plat In the performance a um work forwhIch this parrot is Issued,I
State of Callfomfa,the applIcan.shall have coverage under(1),or(II)desig. shall not employ any parson in any manner w as to eecoma subject to work-
naiad below or shall Indicate(tams(IIP,or(M,or M.whichever Is applicable. orscompensation tam of California.I turner acknowledge that I understand
If however item M is checked Rem(M must be checked es well.Mark the omt In the event that I should become subject to the worker'compensation
apprapdate method of Compliance, pro4lons of the Labor Code of Cellfcmis and fat to comply fenhwit h with
provisions of section 3600 of the Labor Coale,that the permll heroin applied for
LICBNa®CONTRACTORS DECLARATION shall be deemed revoked.
I Iweby samh War:am a domed under dee parddene dehnhwr9(corm endeg wkn I I v. I arafy as tm owns(w the agent for tiro owner)that In the performance of the
sedileffect.m moo:dOi.Idcn s d Ins aWww aM terdawom eerie.and my Ilpar,ea u u ea fere and work for which this permit to Issued.I will employ a contraccor who compiles
with the wadnre'comper atton laws of California and who,prier to the
License374573 elm@ C.TB 05/31/2001 menoement of any work,wall file a cemprated coq of this form with the Central
Permit Bureau,
PAYMENT
ACCOUNT#; 478"437— /7¢ 90 EXPIRATION DATE!
CREDIT CARD TYPE NAME ON CARD: Z6/A( A
TURF: AMOUNTS:
. ,� JAN - 5 2000 Scott Waterbury
Slgn*twmofAp ant DATE Printed Name of Applicant
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
• BUILDING PERMIT INVOICE OPERATOR: chrietya
Sec: Twp: Rng: Sub: Blk: Lot:35613020.00
INVOICE DATE...... : 01/10/2000
REFERENCE ID # ... : 00010029
SITE ADDRESS .....: 10833 WILKINSON AV
SUBDIVISION .......
CITY ...... .. .....: CUPERTINO
IMPACT AREA . .. ....
OWNER ........... .: HOLMES FREDERICK H AND JANALEE
ADDRESS .......... :
CITY/STATE/ZIP ... : CUPERTINO CA, CA 95014-4733
CONTRACTOR .......: MCGEE, PAT LIC # 18986
COMPANY .... ......: WATER HEATERS ONLY
ADDRESS ..........: 500 AIRPORT BLV
CITY/STATE/ZIP ...: BURLINGAME, CA 94010
TELEPHONE ........: (415)349-3747
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 -- DESC=IPTION VOICE IO -.----- DESCRIPTION
..... ............... ........ ..............
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 302 TUB k OR SHOWER
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
• r