00020178 (2) CITY OF CUPERTINO PERMITNO.
'BUILDING DIVISION PERMIT y/' CONTRACTOR INFORMATION: � aro 1 4
RUID r S: I
SANITARY NO. IA
'•P7PLICATION SUBMITTAL DATE
O ER'SNAME: 1 - 77
D ' 7. ^Js '2 OAO
` NIC CONTROLN
PHONC: �N A
i 91
CHITEC(ENGINEER (/ ! , 0 BOLDING PERMIT INFO
Z00
? LICENSED CONTRACTOR'S DEN
CLARATIO
Z
O Z v' I Lneby aRrm the,I w hcemed ower provisions or Chapter 9(canmevcing Job Description
FHCu9 withllforem7000)ofDivision]ortW Busiwa Rofavi a sod myBanco is
4y incerne. ceth-eRa .- � fpj b-v
gro0 Licenro Clus Lic.N
id Date- ,2�D, Comsat. Mxf _
ARCHITECTS DECLARATION
I j, 1 undenund sn pals shall be cad as public records
i ❑o Liceuvd Inamicvl
=ar OWNER-BUILDER DECTARATTON
t"' < 1 berth,affirm dust I am Hemp,from Ne Ciamictors License Lew for the
❑ following raasan.(Section 703 1.5,Business said Profession;Cade:Any city or county
which,equina a permit in covwet,alcor,Imprints,demolish,or rapair any sweturo Sq.Ft.Floor'Area / Valuation
prim the to its Issuance, requires applicant for such permit file le a signed announced ( O
that he is licensed foreman to dm provisionu of the Cnvemota License taw(Chapter 9 '
(<mnnr<vcivgwithSectan7000)mr Division]artheBadaasand!ProressbruCount a APNNumber Occupancy 'Oane e
that he u exempt therefrom and t'coir car she dkgd camptin.AVY violuin a! -3 /] Type .
Sodom
not more man
m Nm n five hundredhundredd by mY epfa a pend abjau uta eppliunt w a civil pew,,of /Y'
dollars($300). �
I,as owner of d'property,or my employees with wept u their sole cornpeacotin, Required Inspections
wW do do,walk, it tommude isnot intended moffeed farsaie(See 7046.Bmim.
and P.Inasiou Cede:The Contractor.License law does not apply to n cavam of
Property who builds or improves thereon,and who does such work himself a through
his own employ',provided ted such improvements ere dm intended a offered for
sale.If,however,the building m improvementa
is sold withinne year areompletiers,IW
owaZda will hese the Whena k of proving shad did nm build m improve fm par
pose of side)
1.as manor of the propeny,s m exclusively connecting with licensed comnactor to
concoct Ne project(Sec.7044,11mirmas eco Profeasiom Cdo)The Camncmr'e U.
cense law dna nm apply to an owvr of property wW Wilds m improves thereon.and +
whe enmacts for such projects with acnes maned(.)licensed pursuant.on Cmurmters t
Lieen'law,
❑l thn eximp,under Sa. ,B&P C for this recon
Own. - Data
WORKER'S COMPENSATION DECLARATION
1 hereby aRrm under penJty of perjury oro of Ire following decluedmu:
I have and will maintain aCenifa'ofCoventto self-imms,far Worker's Comped.
don,as p.Add fm by Sat.3700 of the Labor Code,for the padomtsae of the ,
ork far which this permit is issued.
❑1 have and will maintain Workda Compenntin Resonance.as rquisW by Section
37mofd+e Labor Crede,farta,part.<rda work for which thupered,Is issued.
My Wmk<r's Compnntin Ivausntt card.antl Policy numbs aro:
Cartier. PoseTION FROM
CERTIFICATEOMPE SATION'II NFROM WORKERS' '
COMPENSATION INSURANCE
(This satins need not W comPletedifthe pamtit n Torre hundrd dollen(Sim)
ar ku.) '
I ttnif,mat in the c of the wart for which this permit is iuuedAshall
na employ any perwniyfi gttaN to ItheWorkers'Comp<n-
setitmuns'ofCallfomi(.1q -` �'meAkR V m '
APPlicnt Al
NOTICE TO APPUCVrN7r If,after making this Cenifioe of Exemption,you should
become mb*'to Ne Waiters Compensation provision of the Labor Come,yes mon [
forthwith comply with such provision m this permit stall be deemed revoked.
CONSTRUCTION LENDING AGENCY
O 0 Ibersby ern this dome is constructed leading spiny for die perfonusaea .
IW work for which this permit is issued(STI.3097.Co.C.)
Larder's Name
C > Lenders Add.. - •• -
W Q 1 unify oc 1 have red thinly and county
cod arae that the above laws
muting is
U z correct..agree to comply with ell city entl county.mit'.of this au¢Iews'.port m
.7U O Wilding covwctioo end hucbYnthaaa'pman'tivn of this city to en'r upon the s
above-memioad property for ivp van keep ha.
Ia. F" esti agrees,cove
e ,:damad:damnify skap harmless the City of Cupertino id City _
O ,J I.eastieajdgmenhecourts.and expenses which may in nY war a<n'egaimt said City
A- APPLICANT athe STAN of this permit.
h Q rSOURCHREGUL TIONN.Dg AND WILL.COMPLY WITH ALL.NON-POINT
V hOURCE RIFULATIONS. p
Signawc of AppliunUCoovectm Data
HAZARDOUS MATERIALS DISCLOSURE
Will dd.,Ikam arfue.Wilding occupant store m handle heraaous material Re-roofs '
as dcf cod by the Cupertino Municipal Code,Chapter 9.12,sod Ne Hedtb and Safety
Code,Section 35532(s)7 Type of Roof
❑Yes L]No - -
Will the apPlicnt or morn Wilding acdpnt ase equipmnt or aeric.wnich All roofs shall be inspected prior to any roofing material being
cedt haardne air conumirums are defiad by the Bay Asn Ad Giddily Mnagememt installed. If a roof is installed without first obtaining an inspection
District?
❑Yes F1 No I a ree to remove all new materials for inspection. Applicant
1 eve ..rdaaam. airo"nor" rChapter 6.95ofineCali. un erstands and will comply with all non point source regulations.
roma Hee th ma t code,Sec .505.2ss]7 cod 23574.1 understand that if the
building n0y eve 11 1.on it is my responsibility in notify the occupnt
oldie 'eh mu(b e,6inm'usuerm ofeCnifedeaOccupuay.
L -Co Signature of Applicant Date
Ow r sudwrixed a8nt Da'
All roof coverings to be Class"B"or better
OFFICE,
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
f/
CITY OF CUPERTINO
BUILDING PERMIT INVOICE OPERATOR: karenb
Sec: Twp: Rng: Sub: Elk: Lot:31623039.00
INVOICE DATE......: 02/23/2000
REFERENCE ID R ...: 00020178 .
SITE ADDRESS .....: 10179 N BLANEY AV
SUBDIVISION .......
CITY CUPERTINO
IMPACT AREA .......
OWNER ............: WIELEN GEORGE L AND DAWN S
ADDRESS...........;
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-2329
CONTRACTOR ....... CHAPMAN, ROBERT LIC N 18537
COMPANY ..........: FOREMOST HEATING
ADDRESS ..........: 770 CHESTNUT ST
CITY/STATE/ZIP ...: SAN JOSE, CA 95110
TELEPHONE ........: (408)287-9234
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- --- --------- ------------ -----------
BREMHEAT P 6.11 0.00 6.11
MPERMITFEE P 35.52 0.00 35.52
--------- ------------ -----------
41.63 0.00 41.63
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
. . . ............................ ........ ............................
UNDERFLOOR FRAME 301 ROUGH PLUMBING
ROUGH MECHANICAL 304 ROUGH ELECTRICAL
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 - FINAL MECHANICAL 514 FINAL PUBLIC WORKS
Ory. if Applicable Fee ID Fee Description Fee Group
ISPERNIFEE IBLOG PERMIT FEES JBUiLDING
JBCONSTAX 1CONSTRUCTION TAX 1BUILDING
ISENERGY JENERGY BUILDING
BENERGYADD JENERGY ADD MULTI IBUiLDING
JBOVERTIME IINSPECTION OVERTIME IBUILDING
BTEMPPERM TEMPORARY BLDG PERMIT BUILDING
BMITIGAT HOUSING MITIGATION FEE IBUILOING
BPLANCHK PLAN CHECK FEE BUILDING
SPLANCKADD PLAN CHECK ADD MULTI BUILDING
BPLANCKREP PLAN CHECK REPEAT FEE BUILDING,
BREINSPECT REINSPECTION FEE BUILDING
BSCBLVD SCB SPECIFIC PLAN BUILDING
BSEISMICOM SEISMIC COMMERCIAL BUILDING
BSEISMICRE SEISMIC FEE RES BUILDING
ESPECIAL SPECIAL INSPECTION BUILDING
BSWIM SWIMMING POOL BUILDING
ZADDCHG ADDRESS CHANGE BUILDING
EPERMITFEE ELEC PERMIT ISSUANCE ELECTRICAL
13ELEC1000 ELEC 600V�1000A ELECTRICAL
BELEC1001 ELEC 600V>1000A ELECTRICAL
BELEC200 ELECT SVCS 600V c=200A ELECTRICAL
BNEWMULTI MULTIFAMILY RES ELECTRICAL
BREMBUSWAY REMODELBUSWAYS ELECTRICAL
BREMFIXT LIGHTING FIXTURES ELECTRICAL
• BREMMISC MISC APPARATUS ELECTRICAL
BREMNRAPP REM NON-RES APPLIANCE ELECTRICAL
BREMPO POLEIPLATFORM FIXTURE ELECTRICAL
BREMPOWER POWER DEVICEIAPPARATUS ELECTRICAL
BREMRECEPT RCPTL, SWITCH&OUTLETS ELECTRICAL
BREMRESAPP REMODEL RES APPLIANCE ELECTRICAL
BREMSIGNAD RMDL SIGNS ADD BRANCH ELECTRICAL
BREMSIGNS REMODEL SIGNS, MARQUEE ELECTRICAL
BREMTHEATR THEATRICAL LGHTNG FIX ELECTRICAL
BSF&2FAM SINGLE&2 FAMILY ELECTRICAL
BTEMP TEMPORARY POWER ELECTRICAL
BTEMPSVCS TEMP DIST SVCS ELECTRICAL
MPERMITFEE MECH PERMIT ISSUANCE MECHANICAL11
BAPPLOTHER OTHER APPLIANCES MECHANICAL
BBOT 1 BOILER h 100,000 BTU MECHANICAL
BBOILER2 BOILER>100 O500KSTU MECHANICAL
BBOILER3 BOILER>500KTO im BTU MECHANICAL
BBOT 4 BO R>1M TO 1.75M BTU MECHANICAL
BROILERS BOILER> 1.75M BTU MECHANICAL
BREMAPPLI APPLIANC INSTALL MECHANICAL
BREMHEAT HEATER INSTALLATION MEC
BREMVEN AN VENT FAN SINGLE DUCT MECHANICAL
BMNEWMULTI NEW MULTI-FAMILY RES MECHANICAL
. BMNE01S &2 NEW SF&2 RES BLDGS MECHANICAL
Ir oft
9REMACOVER QAC UNI7 >1CG00CF+L1 SME.-'nNICALI
�BREMAIRHAN JA/C UNITS c= 10,OGCCFNI IMECHANICAL
JBRENIFURN IRELOCATION OF FURNACE IMECHANICAL
BREMFURNOV IRELO FURNACE � 1CK B i U JMECH„NICAL
BREMINHOOO INSTALLATION OF HOOD IMECHANICAL
BREIYIRELOCA IRELOCATION OF HOOD MECHANICAL
BREMREPALT REPAIR/ALTER HEATING MECHANICAL
BREMVENSYS IVENTILATION SYSTEMS MECHANICAL
PPERMITFEE PLUMBNG PERMIT ISSUE PLUMBING J
BNUMULTI NEW MULIFAMILY RES IPLUMBING
BNUSFD NEW SINGLEFAMILY RES PLUMBING
BPBACKFLOW ATMOSPHERIC VACUUM PLUMBING
BPCESSPOOL CESSPOOL PLUMBING
BPFIXTURE PBLG FIXTURE PLUMBING
BPGAS GAS PIPING SYSTEM FEE PLUMBING
BPINTERCEP IND WASTE INTERCEPTOR PLUMBING
SPREPIPE REPIPE OF FIXTURES PLUMBING
SPSEWAGE SEWAGE DISPOSAL PLUMBING
SPSEWER SEWERS PLUMBING
BPSPRINK LAWN SPRINKLER/BACKFLO PLUMBING
BPSTORM STORM/RAIN WATER PLUMBING
BPTRAP KITCHEN TRAP PLUMBING
BPVENT ALT OF DRAIN &VENT PLUMBING
BPWATER INSTALUALTER WATERPIP PLUMBING
BPWHEATER WATER HEATERNENT PLUMBING
BPWSVCS MAIN WATER SERVICE PLUMBING
ZDEVAGREE DEVELOPMENT AGREEMENT PLANNING
ZDIRTM DIR TENT MAP up
ZFULLHR FULLAPPLBASE+HR
ZFULLTM FULL ADPL TENT MAP ZFULLUP ULL APPL USE PERMIT ZFULLZONE FULLAPPLZONING ZGPAM ND GENERALPLANAMEND ZLIMAMEND LIMITED AMEND
ZLIMTM LIMITED TENT MAP PLANNING
ZLIMUP LIMITED APPL USE PERMI PLANNING
ZMATEMPUP MIN AMEND TEMP USEPERM PLANNING
ZMINHILLEX MINOR APPL HILL EX C PLANNING
ZMINSIGNEX MISC SIGN EXCEPTION PLANNING
ZMINTM MINOR APP TENT MAP PLANNING
ZMINUP MINOR APPL USE PERMIT PLANNING
ZMISCASA MISC ARCH SITE PLANNING
zMISCr MISC TM AND UP PLANNIN
ZMISCFENC5 MISC PENCE EXCEPTION PLANNING
ZMISCG N MISCELL ADPL GENERAL PLANNING
ZMISCPCINTMISC PC INTERPRETATION PLANNING
ZSIGN SIGN PERMI PLANNING
MPSIGN TftMPQKAKT SIGN PLANNING
ZVARIANC DIRECTOR VARIANC PLANNING
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