00010070 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERNUTNO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
'"S j,i;h BUILDING PROJECT IDENTIFICATION,lilt r 'IB
BUILDING ADDRESS: / SANITARY NO. APPLICATION SUBMITTAL DATE
343
OWN NAME O� ! 0e� NE: 9/� C A5 OR je NAME; �LICN i�
VV- Nll' CONTROL#
ARCHITECIMNGINEER: LIC NO: ADDRESS: ❑
NTACT: - PHONE: F' pet,!; !BUILDING PERMITINFO!. a;
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
/9NStFLoT/1,*.e f131-.Z39 ❑ Ga! ❑ ❑
LICENSED CONTRACTORS DCCLARAHON Q71' ? ' ai 'Bf.EC;TRIfi PERMIT, + }III I }..Ffrl. til'
I beret,officer flan licensed a p .. of Chapter 9 momme g P' . ..�t,z I. ''- JOB DESCRIPTION
FwOZO with Section 9(N1H)af D' isinn3 of,he Busln. and Pmfosslous Code,and my Intents,cs PERMIT ISSUANCE RESIDENTIAL:
F in full force and effect. ❑SFDWL ❑KITCHEN REMODEL
�OV Wemse Clens Lia# APPLIANCES-RESIDENTIAL CADDITION OPLUMBING RE-PIPE
Dale Contractor
ARCHITECT'S DECLARATION [I MULTI-UNIT El STRUCTURAL
zoaz I undersand my pIga,,hall neared as publicruords PANELS MODIFICATION
OZ'-O UP To 21x1 AMPS [_1 INTERIOR El CHIMNEY REPAIR
.I=ron 1"'W Licenses)Professional 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
Zg OWNER-BUILDER DECLARATION OVER 1000AMPS El BATH REMODEIJREPAIR [I DEMOLITION
W I hereby affirm Thal I am exempt from the Contractor's License Law for the
x O 0.V following mems a (Semicon 9031.5,Business and Professions Code:Any nary or county structure SIGNS ELECTRICAL El MITER
3 0.y which requires a permit to cnnstmch nifeq improve,demolish,or repair any stmewre rBA
0� priorto its issuance,alsorequires theappllcam forsuch permit o filo a slgnedsmmaint SPECIAL CIRCUITIMISO �—Q
cal that he is licensed puraoant to the provisions of the Contractor'x License Low(Chapter 9
(commencing with Section 7000)ofDivision 3 of the Business and Professions Code)or TEMP.METER OR POLE.INST.
that he is exempt therefrom and the toris for the alleged exemplir EW BLDG/ADDHION ❑DEMOLITION
mW Section 7031.5 by any applicant far a permit s.hjects the applicnm rpnlry O 1 5 ❑FOOD SERVICE
.Z.N not morn than five hundred dollars($500). NANT
2+SC ❑ Lies owner of the property,ovary employees with wages as Mei a G OVEMBNT
will do the work and the eVac,ure is not intended or offered far aide(Sac.7044,Business OTHE
{ai] and Pro[naslons Code:The Contractors License Low does not apply t f O IT
proper,who M1uilds m inrpnrves thereon,nnJ who does such work Aims I unlop
to
stga
his awn employees,provided thin such impmvemm�ts ere not intended r oIL
Brad I SQ FE
sale.If,however,thehuilding nrimproveaientis sold within one yearofc tZ$.FLOORAREA t $/SQ.Fr.
b 'id llhave the h de fp gthth did not build improvefrpu #�''�(��
P ale.).
1 ne Of the property exclusively Vaca ng ilh I' , O
t t lh p ) t(S 9044 Bu,n s. and Pr f s ro
s C do 0 - I -
xla des t apply to fproperty h builds or a e FEE
who contrachs for suehpjems with a contrucmus)Icensed pursuant to the Contractors err •1'
License Law. PERMIT ISSUANCE
❑ 1 am exempt under Sec. ,B&P C for this reason
Owner Date
ALTER-DRAIN&VENT-WATER(EA) VALUATION
'
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the following declarations:
aIhave and will mainmin a Cerificmeof Consenun self-Irovre for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,CONCOND. S'IDRIES TYPE CONSTRUCTION
rkna provided for by Section 3700 of me Labor Code,for the performance of We
for which this permit is Issued. FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensidem Insurance,as required by Section
3700 of(lie Labor Code,for the performance ofthe work for which this permit is issued. GAS-IA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP p APS(
My Workers Compensation Insurance carrier and Policy number aa: ` C.!
Carrier: Policy Na: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEM I'T]ON FROM WORKERS'
COMPENSATION INSURANCE GREASEIINDUSTRL WASTE INTERCEPTOR
(This trade.need not be completed ifthepeonal is for one hundred drain,p$100) s 4 y-'.v.4 =BUIL IN I �, ,
or less.) GREASETRAP PLANCHECK FEE
I certify that in me performance ofthe work for which this permit is issued.Ishall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in may manor so os m become subject ,the Workers'Carmen- ENERGY FEE
Z sinner Law,of California.Data
Z O Applicant WATER HEATER W/VF.NT/ELELTk GRADING FEE
y NOTICE TO APPLICANT.If,after making this Cerificme of Exemption,you should WATER SYSTEMITREATING
aibecome subject m me Walker,Compensation provisions of the Labor Code,you as, SOILS FEE _
W famhwuh comply with such provisions or this permitshall be deemed revoked. WATER SERVICE
Q
CONSTRUCTIONisoa,uLENDING AGENCY NEW RESIDENTIAL PCMB. $Q.FT. PAID
VO work
rwhichthi thvuhereisa ed(Sec.30 lending7,Cagency for the performance of Da,e Receipt#
O Trances
for which this permit is issued(Sec 3(199,Civ.CJ r1 �/ =� i Com'
ULenders Name t, T TAC:
Lender's Address TOTAL: _
1 certify that l have mad this application d statethat the above information i., ,. I I ,,. � BUILDING PEE
V1 recover gree, comply with all city and equityordinances and suite laws calming t :,-. , } �p
gr y presenuitives of to enmrt,nvthc QTY .NIBCHAMGAL PERMIT ,-,p,2000
~ fa L
U Z building n,tnm'mn endh b authorize l� s s.. e} � -�t�� ^14t` 1
above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless me City of Caperton against PERMIT ISSUANCE ELECTRIC FEE
liabiiities,judgmenm,costs andexpenses whichmay in any way scans againsterid City ALTER Ok AUU TO MECH. Gj PLUMBING FEE
in consequence of the granting of this pwmit. _
APPLICAN UN E uf��TANDS AND WI COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 14000 CFM) MECF(ANICACPE—
SOURCE P R BNS.
^2: 0 AIR HANDLING UNIT(OVER IO,(IOO CPM) CONSTRUCTION TAX
Si�res A cznucnatmenor Dam EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant in future building eccupant_store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as dented by the Cc....nm Municipal Cade,Chapter 912,and the health sad Safely
Code,Section 25532(a)? HEATING UNIT(OVER 100,000 BTU)
Yes ❑NmPAID
VENTILATION FAN(SINGLE RESID) .Date Receipt#
Will the applicant or it banding by the Buse
co Air unt ordevices which BOILER-COMP(3HP OR 100,0011 BTU)
emit hazardous air ennwminana ns defined by rho Bay Area Air Quality Management TOTAL.
C
r-1 Yes No BOILER-COMP(OVER 100,000 BTU)
I have read the hazardous materials regairemeres under Chapter 6.95 of the Cnll- AIR CONDITIONER- ISSUANCE DATE
forme Health Safety C41b.Sections 25505,255 end 25534.I understand that if,he NEW RESIDENTIAL MECH. SQ.FT.
bld
uiingd cupant ter hnveate nk that i' yreapnnxibilirymnotily the oc
ofthere i w ch ain't he a p- sofa Cerifieam ofOcy
cupaAJ�c4
commonest agwt IF IData TOTAL: ISSUED BY.
4` OFFICE
CITY OF CUPERTINO
Item 1 Of 1 BUILDING PERMIT RECEIPT OPERATOR: karenb
COPY # 2
Sec: Twp: Rng: Sub: 31k: Lot:36202027.00
DATE ISSUED...... . : 01/12/2000
RECEIPT #......... : 11151
REFERENCE ID # ...: 00010070
SITE ADDRESS .. . . . : 10840 BUBB RD
SUBDIVISION . . . . ...
CITY ..... . . . . . . . . : CUPERTINO
IMPACT AREA ... .. . .
OWNER DEBCOR
ADDRESS . . . . . .....:
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4964
RECEIVED FROM .... : TIM
CONTRACTOR .. .....: LIC #
COMPANY .... . . ... . :
ADDRESS .......... :
CITY/STATE/ZIP ... .
TELEPHONE ... . ....:
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW HAL
__________ _____________ __________ __________ _____ _______ _
HTEMP FLAT RATE 1.00 57.50 0.00 57.50 0.00
BUSLIC FLAT RATE 1.00 90.00 0.00 90.00 - 0.00
EPERMITFEE FLAT RATE 1.00 35.52 0.00 ,35.52 0.00
T'"irL PERMIT 183.02 0.00 183.02 0.00
OF PAYMENT AMOUNT NUMBER
____________ __________________
OTHER 183.02 VISA
TOTAL RECEIPT 'mmSL6183.02
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
........ ..........................— ........ ............................
103 UFER 304 ROUGH ELECTRICAL
Ory. if Applicable Fee ID Fee Description Fee Group
1SPERMFEE (BLDG PERMIT FEES BUILDING
ISCONSTAX 1CONSTRUCTION TAX 1BUILDING
ISENERGY (ENERGY BUILDING
BENERGYADD JENERGY ADD MULTI IBUILDING
SOVERTIME JINSPECTION OVERTIME ISUILOING
BTEMPPERM ITEMPORARY BLDG PERMIT IBUILDING
BMITIGAT IHOUSING MITIGATION FEE 1BUILDING
BPLANCHK' PLANCHECKFEE . BUILDING
BPLANCKADD PLAN CHECK ADD MULTI BUILDING
BPLANCKREP PLAN CHECK REPEAT FEE BUILDING
BREINSPECT REINSPECTION FEE BUILDING
BSCBLVO SCS SPECIFIC PLAN BUILDING
BSEISMICOM SEISMIC COMMERCIAL BUILDING
BSEISMICRE SEISMIC FEE RES BUILDING
BSPECIAL SPECIAL INSPECTION BUILDING
BSWIMSWIMMING POOL BUILDING
ZADDCHG ADDRESS CHANGE BUILDING
EPERMITFEE JELEC PERMIT ISSUANCE ELECTRICAL
BELEC1000 ELEC 600V r_1000A ELECTRICAL
5ELEC1001 ELEC 600V>1000A ELECTRICAL
BELEC200 ELECT SVCS 600V <=200A ELECTRICAL
BNEWMULTI MULTIFAMILY RES ELECTRICAL
BREMBUSWAY REMODEL BUSWAYS ELECTRICAL
BREMFIXT LIGHTING FIXTURES ELECTRICAL
BREMMISC MISC APPARATUS ELECTRICAL
• BREMNRAPP REM NON-RES APPLIANCE ELECTRICAL
BREMPOLE POLE/PLATFORM FIXTURE ELECTRICAL
BREMPOWER POWER DEVICE/APPARATUS ELECTRICAL
BREMRECEPT RCPTL, SWITCH &OUTLETS ELECTRICAL
BREMRESAPP REMODEL RES APPLIANCE ELECTRICAL
BREMSIGNAO RMDL SIGNS ADD BRANCH ELECTRICAL
BREMSIGNS REMODEL SIGNS, MARQUEE ELECTRICAL
BREMTHEATR THEATRICAL LGHTNG FIX ELECTRICAL
SSF&2FAM SINGLE&2 FAMILY ELECTRICAL
STEMP TEMPORARY POWER ELECTRICAL.
BTEMPSVCS TEMP.DISTSVCS ELECTRICAL
MPERMITFEE IMECH PERMIT ISSUANCE MECHANICAL
BAPPLOTHER OTHER APPLIANCES MECHANICAL
BBOILERI BOILER<=100,000 BTU MECHANICAL
BBOILER2 BOILER>100KT0500KBTU MECHANICAL
BBOILER3 BOILER>500K TO 1M BTU MECHANICAL
BBOILER4 BOILER>1M TO 1.75M BTU MECHANICAL
BBOILERS BOILER> 1.75M BTU MECHANICAL
BREMAPPLI APPLIANCE INSTALL MECHANICAL
BREMHEAT HEATER INSTALLATION MECHANICAL
BREMVENFAN VENT FAN SINGLE DUCT MECHANICAL
BMNEWMULTI NEW MULTI-FAMILY RES MECHANICAL.
BMNEWSF&2F NEW SF&2F RES SLOGS MECHANICAL
• k aft
Revised NI0199
s
9REMACOVER IAC UNIT >IO000CF&I IiV1ECHANICAL�
JBREMAIRHAN IANC UNITS <= 10.00CCFtl1 (MECHANIC?L
BREiNIFURN IRELOCATION OF FURNACE MECHANICAL
BRENIFURNOV IRELO FURNACE > 10K BTU �NIECHANICAL
BREMINHOOO JINSTALLATION OF HOOD MECHANICAL •
BRENIRELOCA RELOCATION OF HOOD MECHANICAL
BREMREPALT REPAIR/ALTER HEATING MECHANICAL
BRENIVENSYSVENTILATION SYSTEMS MECHANICAL
�PPERMITFEE PLUMBNG PERMIT ISSUE PLUMBING
SNUMULTI NEW MULIFAMILY RES PLUMBING
BNUSFO 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
BPSEWAGE SEWAGE DISPOSAL PLUMBING
BPSEWER SEWERS PLUMBING
BPSPRINK LAWN SPRINKLER/BACKFLO PLUMBING
BPSTORM STORWRAIN WATER PLUMBING
BPTRAP KITCHEN TRAP PLUMBING
BPVENT ALT OF DRAIN &VENT PLUMBING
BPWATER INSTALL/ALTER WATERPIP PLUMBING
BPWHEATER WATER HEATER/VENT PLUMBING
BPWSVCS MAIN WATER SERVICE PLUMBING
ZOEVAGREE DEVELOPMENT AGREEMENT PLANNING
ZDIRTM DIR TENT MAP PLANNING •
ZFULLHR FULL APPL BASE+HR PLANNING
ZFULLTM FULL APPL TENT MAP IPLANNING
ZFULLUP FULL APPL USE PERMIT IPLANNING
ZFULLZONE FULLAPPLZONING PLANNING
ZGPAMENO GENERAL PLAN AMEND PLANNING
ZLIMAMEND LIMITED AMEND PLANNING
ZLIMTM ILIMITED TENT MAP PLANNING
ZLIMUPLIMITED APPL USE PERMI PLANNING
ZMATEMPUP MIN AMEND TEMP USEPERM PLANNING .
ZMINHILLEX MINOR APPL HILL EXC PLANNING
ZMINSIGNEX MI C SIGN EXCEPTION PLANNING
ZMINTM MINOR APP TENT MAP PLANNING
ZMINUP MINOR APPL USE PERMIT PLANNING
ZMISCASA MISC ARCH SITE PLANNING
ZMISCEXT MISC TM AND UP ExT PLANNING
ZMISCFENCE MISC FENCE EXCEPTION PLANNING
ZMISCGEN MISCELLAPPL GENERAL PLANNING
ZMISCPCINT MISC PC INTERPRETATION PLANNING
ZSIGN SIGN PERM[ PLANNING
ZTEMPSIGN TEMPORARY SIGN PLANNING
�ZVARIANCE DIRECTOR VARIANCE PLANNING
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