S 2922 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
� CITY OF CUPF,R'1'INO BUILDING-ELECTRICAL
PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDING DNESS: =N�ICCO
O (! S SME PHO -�AjS CO TRACTOR'S NA E: LIC NO:ls)j
'Cyn
AH HIIECDENGINEER: LIC NO: IT '$�: Mal 4111,R 5/ �
CONTACT. PHONE: II BUILDING PERMIT INFO
❑ cramodtamt Fees Paid by Applicant(Initial) BLDG ELECPi PLUMB MECH i
LICENSED CONTRACTOR'S DECLARATION QTY ELEC'fHIC PERMIT FEE JOB DESCRIPTION
1 hereby affirm mut Imo IiccmW nndet provisions of Chapter 9(.mmmm�.ing
�4'Z with Sectinn"IINXq of Dlvisimt3ol rhe Business anJ Pnde.esions Cale,and my license is RESIDENTIAL:
O PERMIT ISSUANCE
FUr in full farts and cif Y D ❑SFDWL ❑KITCHEN REMODEL.
QUV Licence Cla- - _ Lich APPLIANCES-RESIDfENTIAL ❑ADDITION El PLUMBING RE-PIPE
F Z m Dam Convucun
r/I¢4 El MULTI-UNIT ❑STRUCTURAL
P. y ARCHITECTS DECLA %TION PANCLS MODIFICATION
zbyK I understand my Plans shall be used as public cards UPT02(gIAMPS
0t+Z4o ❑INTERIOR El CHIMNEY REPAIR
a.14 t Llansed Pmlessianal 201-110(IAMPS IMPROVEMENT SWIMMING POOLS
�WNN, OWNER BUILDER DECLARATION OVER IINOAMPSI—
and
❑BATH REMODEIIREPAIR ❑DEMOLITION
C Q I hereby affmt that 1 am exempt from the Cantraclor's License Law for me
iqqiS5 O'W U dilating ing reason.(Sudan 9031.5,Bminas,lard 11 bastions Cods:Any ciy o,.only SIGNS ELEMICAL ❑OTHER
n+3 w in which regm own permit to comport,alter,improve,demolish,or repair any spactdre im LE,
prior to its issuance,also requires the applicant for such perminn lire as signed statement SPECIAL CIRCU ITIMISC.
2 Y That he is licensed pursaam ,,the prnvisiomoflha Contractor.,Lic.nse Law(Chapsr9
alp (commencing with Section 7001 Division Sof the Business and Professions Carol or 'TEMP.METER OR POLE INET.
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
:2on Section 7031.5 by any applicuat lit u permit subjects the applicant to a civil penally of POWER DEVICES ❑TENANT ❑FOOD SERVICE:
.,,.,a man rise hundred dollars(E51X). IMPROVEMENT
C~�Q ❑I,as nwnernfine properly,ar my employuswith wagesas m.irarle romp.nsatinn, SWIMMINGROOLIELIECI'RIC ❑OTHER
YY will do Ne work,and the xwamre is net intendWnrolfered tarsal.(Sec OIW,ffirouas
L Professions Cale:'fhe Contmetors License Luse dues not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself m through
his awn employ.,provided that such improvements are not intended or offered tot NEW RESIDENTIAL F:hECfR
FF.FLUOR AREA E/SQ.FT.
sale.If,however the bdildingorlrprovement issold widunoneya.,of campletino,Lha .
Ly A
cr-builder will have the burden of proving that he did nut build or improve for Pur-
psneofodO.).
EJhas swner of the prnpeny,um exclusively rommaing with IicenseJ c..mochus to TOTAL:
construct the project(Sts.90,14.Business and Professions Cede)The Contractor's Li-
cameLawdoesnolapplymartownerofprnpeny who builds or improves driver,and QTY. PLUMBING PERMIT FEF.
who cc ntracls for such pmjcets with a comractar(s)licensed pursuant to the C'ontractor's
License Law.. PERMIT ISSUANCE
1 it,exempt under S.. ,B Or P C for this reason
Owner Date
ALTER-DRAIN S VIENI'-WATER MA) VALUATION
0
Wm underPCOMPIPerjur on DECLARATION as BACK FLOW PROTECT DEVICE
I hereby affirm under pclmhy of perjury one of the fnllnwing declarations:
'-Inn,as and will far byetion irate of'he Lid),Codimal'he WorkersCompcm UHNNS-PLOOR,ROOF.AREA,GOND' SDRIES TYPE CONSTRUCTIOF
as provided for by Section 3"I(ra of the Lahnr Gula,for the perLmnnna of the
ork for which this permit is issued. FIXTURES-PER TRAP
have and will maintain Worker's Compensation Insurance,as required by Section
.) ofthe Labor
Cpode.for the perl'armance,of the work ffofrr jwlhich this perntil is issued. GAS-EA.SYSHEM-I INC.4 OUTLETS OCC.GROUP APN
My WorriCN IT pion{gpuotCr ,cartirrPi do Pilot,y Na.:
Rib
My Wo r. 11 1 `� 9 n11n�Aps GAS-EA.SYSTEM OVER 4 I EA) /D
CIERIFFICATIE OP EXEMITION 12ROM WORKERS' GREASFJINDUS'TRI.WASI'IiIN'IERCEITOR
COMPENSATION INSURANCE BUILDING DIVISION ITHS
(Thistection mud not hecnmplatadifthe permit is bailout,handled dollars r$IBB) GHEASETRAP
or rev.) PLANCIIF.CK PEE
I unify that in lite amfnrmancaof the work for which this pemtlla issued,Inhall SEWER-SANITARY-STORM F.A.200 FT.
ern employ any Parson.n'any manner so llw he nuc mM1ject dt the Weaken,Compen- ENERGY FLEE
O Z s:aion Law. Califmmia.Da¢ - T 001 - WATER HEATER W/VENT/IELECfR
O APPA 1 at"dCV 4- )�.�_o__ GRADING FEE
N Cti A LICA :It,a er ktng t is Cenifcot.of Exemption,you should WATER SYSI EMTREATING
4 beer emrbj.et the Workers Ca Rsatimi tpaskiomofinelmMr Coaduyuumust _ SOILS PEP.
rte. fonhw esupply ilh such Provisions nr this permit shall k deemed revoked. WATIER SERV ICE
Q
a'
CONSTRUCTION LENDING AGENCY NEW RISIDEN'OAL PLMB. SQ.1q. PAID Date Reeelpl R
V C) I hcrehy alTtmtlhot mere iso constructionlendingagency for the performance of
w 6-r the wod for which this permit is i...Od(See 3097,Civ,C.) TOTAL:
0 U Lenders Name
Lenders Address TOTAL:
tl 1 unify that I have read ibis application and state that the aline rationalist a BUILDING FfJi
F h corrat.I agree to.mply with all city unit roomy ordinances and sum laws relining to QTY. MECHANICAL PERMIT FEE SEISMIC FEE
V Z building contraction,and hereby admon,O,representatives ofthis city to enter upon the
alwve-mentioned prapeny for Impatinn Purpose'. PERMIT ISSUANCE ELECTRIC FIEIE
(We)agree m rove,indemnify and kap homdeu the City of Cmpcnina Outcast
I'mhililds,judgmcnts,leotard enpvr,cs whichan,in any way accmc ageirstsuid City AFTER OR ADD TO MECH. PLUMBING FEE '
in .....re me of th.gtaming of leis permit.
APPLICANT UNDERS ANDS ND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL PEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
7tilmolApplaimpLonamelor D:ue IEXHAUSTHOOD(WIDUC) HOUSING MITIGATION FRI;
HAZARDOUS MATERIALS DISCLOSURE.
Will meapplicatno future boldingoccupant scoreorhandle harardous material T
HEATING UNIT(TO 1(0,(X0 II'HA
as defined by the Cupertino Municipal Cale.Chapter 9.12,and he health and Safety
Colo,Section 25532(0)'! HEATING UNIT(OVER 100J000 B'I'Or
E]Y" PjNo VENTILATION FAN(SINGLE RLSID) PAID
Dae ReceiptM
Will the applicintt m furore LSuilding Perdition air equipabot or callus which BOILER-COMP UHP OR 1(X1,000 BTUI
1W I mit broadens air condminmds as defined by the Bay Area Air Quality Management TOTAL:
t9 - / BOILER-COMP(OVER 100.00 BTU) �j—
�
I pave ruJ me ho,orkas mnrerub,rcquiremena under Chapter 6.95 ofthe Cali- AIR CONDITIONER ISSUANCE DATE:
frmia Halm Ar Safety Cale. 'anions 25505,25533 and 25534.1 understand fled it the NEW RESIDENTIAL MECH. SQ.PI'.
bit' n t Fly cal 60141 It is my re,pmrsibirily to n lily the occupant
me reqs s et prion is.ante of a C 'sate upa
Ow um zed age. Data TOTAL: ISSUED BY:
� OFFICE
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
BUILDING PERMIT INVOICE OPERATOR: nencyc
1
- Sec: Twp: Rng: Sub: Blk: Lot:36211061.00
INVOICE DATE......: 03/29/2000
REFERENCE ID # ...: 00030183
SITE ADDRESS .....: 1184 BUBB RD
SUBDIVISION ...... .
.CITY .............: CUPERTINO
IMPACT AREA ...... .
OWNER ............: WASSON ROGER E AND LILLIAN H
ADDRESS .......... :
CITY/STATE/ZIP ...: CUPERTINO CA, 95014-4966
CONTRACTOR .......: ATKINSON, THOMAS LIC # 141
COMPANY ..........: VALLEY HEATING R COOLING
ADDRESS ..........: 1171 N 4 TH ST
CITY/STATE/ZIP ...: SAN JOSE, CA 95112
TELEPHONE ........: (408)294-6290
FEE DESCRIPTION CHR TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- --- --------- ------------ -__--------
BREMAIRRAN - P 8.33 0.00 8.33
BREMHEAT P 6.11 0.00 6.11
BREMRECEPT P 1.11 0.00 1.11
EPERMITFEE P 35.52 0.00 35.52
MPERMITFEE P 35.52 0.00 35.52
86 59 0.00 86.59
OB ID -..--- DESCRIPTION -- _- VOICE ID EEEEEE DESCRIPTION
303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL
505 FINAL ELECTRICAL 508 FINAL MECHANICAL
•
Ory. if Applicable Fee ID Fee Description Fee Group
' ISPERNIFEE ISLOG PERMIT FEES (BUILDING
�BCONSTAA 1CONSTRUCTION TAX ISUILDING
�SENERGY ENERGY IBUILDiNG
• SENERGYADO JENERGY ADD MULTI JBUILOINQ
1BOVERTIME JINSPECTION.OVERTIME IBUILDING
BTEMPPERM TEMPORARY BLDG PERMIT 113UILUINQ
BMITIGAT 1HOU51NG MITIGATION FEE IBUILDING
SPLANCHK IPLAN CHECK F IBUILDING
BPLANCKADD PLAN CHECK ADD MULTI BUILDING
SPLANCKREP PLAN CHECK REPEAT FEE BUILDING
BREINSPECT REINSPECTION FEE BUILDING
BSCBLVD SCB SPECIFIC PLAN BUILDING
BSEISMICOM SEISMIC COMMERCIAL BUILDING
BSEISMICRE SEISMIC FEE RES BUILDING
BSPECIAL SPECIAL INSPECTION BUILDING
BSWIM 1SWIMMING POOL BUILDING
ZADDCHG JADORESS CHANGE BUILDING
EPERMITFEEELECPERMIT ISSUANCE ELECTRICAL
BF-LLC1000 ELEC 600V�1000A JELECTRICAL
BELEC1001
ELEC 600V>1000A ELECTRICAL
BELEC200 ELECT-SVCS 600V <=200A JELECTRICAL
BNEWMULTI MULTIFAMILY RES JELECTRICAL
BREMBUSWAY REMODELBUSWAYS JELECTRICAL
BREMFIXT LIGHTING FIXTURES JELECTRICAL
BREMMISC MISC APPARATUS JELECTRICAL
• BREMNRAPP IREM NON-RES APPLIANCE ELECTRICAL
BREMPO POLE/PLATFORM FIXTURE ELECTRICAL
BREMPOWER IpOwER DEVICEIAPPARATUS ELECTRICAL
BREMRECEPT RCPTL, SWITCH &OUTLETS ELECTRICAL
BREMRESAPP IREMODEL RES APPUANCE ELECTRICAL
BREMSIGNAO RMDL SIGNS ADD BRANCH ELECTRICAL
BREMSIGNS REMODEL SIGNS, MARQUEE ELECTRICAL
BREMTHEATR THEATRICAL LGHTNG FIX ELECTRICAL
SSF&2FAM SINGLE&2 FAMILY ELECTRICAL
BTEMP TEMPORARY POWER ELECTRICAL
BTEMPSVCS . TEMP DIST SVCS ELECTRICAL
MPERMITFEE IMECH PERMIT ISSUANCE MECHANICAL
BAPPLOTHER JOTHER APPUANCES IMECHANICAL
IBBOILER1 1BOILER<= 100,000 BTU MECHANICAL
BBOIL.ER2 IBOILER>100KT0500KBTU MECHANICAL
BBOILER3 JBOIILER>500K TO 1M BTU MECHANICAL
BBOILER4 BOI >1MTO1.75MBTU MECHANICAL
BROILERS BOILER> 1.75M BTU MECHANICAL
BREMAPPU AP—PUANCE INSTALL MECHANICAL
BREMHEAT H NS ALLATIONMECHANICAL
BREMVENFAN VENT FAN SINGLE DUCT MECHANICAL
BMNEWMULTI NEW MULTI-FAMILY RES MECHANICAL
9MNEWSF&2F NEW SF&2 RES BLOGS MECHANICAL
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