00050060 (2) CJ sat DING DIV sIONNO CONTRACTOR INFORMATION: PERMIT NO,
PERMIT / t r / 0005706-1)000s
BUILDING ADDRESS: /a�'/✓' G• ,SVNS SANITARYNO. APPLICATIO SUBMITTAL DATE
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PHONE:
gRCHR[CT/ENGINEER OULDINO PERMIT INFO
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a' Z LICENSED CONTRACTOR'S DECLARATION
F
o z,i- I hncby aRren Nw at I licensed under provisions of Chaplin mmmi
9(caeog - Job Description
1 �t'u9 with Sectim TJJO)of Division
Sof Ne Business and Profeaiom Code.andmY liantt is
eC' a infullfores, affect.
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mass CII ti
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O I'• Dete�liJ�Conu I tu-iOpa¢p " ARDECLARATION
.I undenwd any PHm"IW used u postage rttwds
as
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n Wcemcd Rofeuiaml ( ��/ J/ (�/
OWNER-BUILDER DECLARATION
l I bertby.(Stns(Swine
I,m eaempt Pram the Gaatns Coe e:My c Lew cr the - - -
$ m following^Aron(Section]031.5,Bminaa and ove.de mi Cade:MY city m county -
d which rtqube.#amidrecmesthe slur,improve,demolish,fieapsigany omens Sq. FL FloorAtea Valuation
primwslissfuna,alwrequires Nr.pions fishash Conpermit Lice se Lawdmtement
Net he is lianttdpuesugatction to de,700E.ffhvWna Sore eBu.... Llaatt Lgim.Co s).
oug
(c,heis ing widtSectian]U80)ofDivieiofr thohneincaend ProAnyvi Codnof APN Ful OccuaniType. '
Jut he is 31 rob my ,li unt Ju buil far Ne u than exemption.AnY violation of - P Y
not.inl S by hundred
dollarm,pemut wbjectathe applicant his civil p<wryof, 3�2� OO
tux nxm Nen five hundrtd dollua($Sdo).
❑Lasowmrk,and
desemy,mmY.imurea wiNwsgeutlrirwk compensation. Required Inspections
will Profdo won,Code: in,C h I...inuoded Lew sed dos .apply 1.an Bvrear a r
and erty who
Code:inapt C of ther r'a Lianas do tlma nm weds
to lf owner of - - -
property who builds or vided th thereon,and who da,such work ded or or J el far
his own ewaver.n,Provided Jw aunM1 impros sold w nrt nm intended er oReutl fm `
We.ILhavuee ithebuildingarimpmemenl is at withint yerofclprow farur
pose.fsah) will teas Ju burden o/proving that M did trot buBd m improve fm pun-
Pott tar We.).
1.u owner of Ne propeM•am exelmivelY conuectin8 with licensed ebntncmn to
construct Ne projet(Sec.]BCA,Busmcu end Rvfesslom Cade:)The Conuactor'e W- - -
cense taw does rwt apply m w awns of property who builds m improve Cmw and
Lear.Lawsfmsuch projmta wiNeconuwtor(s)licenttd pusuantmrhe Convactols
Lianu Law. (�"a -
❑IunexemptunderSec.- .B APCfm Nia ration ,
Owner Data -
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury,ons of dr following decluadoro:r-11 have and will meintun a Cemficuc of Comam to ttl6insum fm Wodues Com
Pan.
sation.as provided for by Section 3700 of the labor Cade.for Ne pi fomunea of Nn ..
work for which Nis permit is issued.
-❑1 have end will maintain Worltces Compensation Insurance,ss required by Section -
3]g0ofdrLebwCode,fmUrperfonrun oftha wmk for which Nis pamitu issued. '
MY Wmkc/`jrglpfaj n A c antl PoIICY
Camey: 4—�y[y Iicy RO:'j_(.L' LLLL ,
CE TIFlCATE OFSATIONIEXEMPTION FROM WORKERS'
Ct W cum ATION INSURANCE
(This ttainn neednot be compleud i(Ne pemdt is foromhundred ddless(I IM)
or leu.) -
i unify that
per in the my ans w r se as t wmk for which Nia t emelt is issued.Domes-
nm employ any person in any menmr w ea m become.ubject to dr Wartrn'Compen-
Applic.nWe of California.Dean -
' Applicant - ..
NOTICE TO APP WC worker,cWhra agi this Certificate of Laim,iode.you
ould
bttamescounpyct it workers Compeor this protshal of Ne labor ,.k you amt
IOMwiN cmnplY with such provisions m this permit still be teemed revoked.
0 0 _ CONSTRUCTION LENDING AGENCY
- Ihemby affirm Net Vert isacomwcJon lending agency fmthe d....f -
Z Ne..it for which one permit is issued(Sm 3097.Civ.C.)
Fro Laace,ls Num
Qv, 7 landch Addrtu '
W' I,enify that 1 have reed on.applicatien stau Nen al ve infomudon is „
0+ z
.contract,1 e8nee to comely withell city eM c n1Y rdinemee d s u dews relaun8 to
r'7 building conswetion,tied mby authorize utiveanf lytoenurupon d.
U O above-numiomd Property inspm loop r
Is., E„ LU�CAZIJNK
rte nave 'urdcnwify end v len Ci tar Cupmire against
0 V sacs and npentta Site Yin anY eY rve agumt acid City
r� of g in8 of Nia a it. .
F.R9'.NDS ANDW LC MPLYWI'II LL NON-POINT a
V UI_TI(
X10
gm a(ApplicUHUCG,—
HAtm�� RSRIALSDISCLOSUREWi1lNeappfit ascompterstoreorhandlehazudousmewnal Re-roofsd< redbNeC Muni, Code,chapter 9.12,tad the Heath and Safetyc section M53Type of Roof
❑Yes [I No
Will the applicant or far.buil n u e e9uipmem m devices which All roofs shall be inspected prior to any roofing, material being
emit huadous air con dmnts as de w the . Moi Au Qudily Menaement installed. If a roof is installed without first obtaining an inspection
District? I a ree to remove all new materials for inspection: Applicant .
.
Y. s C]No g
I have Ne ma A taundor Chapter 6.95 of Ne Cali- Understands and will comply with all non point source regulations.
I. IedN Sefay ,Seed 25 ,25 end 25530.1 understand that if the .
uildin doesn tura
haver
a un 1, titi spomibilitymnaifY the occupant
Ne air a rote must be t p w u of a Certificate of Occupury.
Signature of Applicant Date
na ant Date ' '
All roof coverings to be Class"B"or better
OFFICE .
EIRE,%MACOVCO QAC UN17 >IGGOGCFSI IMECnANIC L
jBREMAIRHAN 1A/C UNITS <= 10:000CFd,I IMcGriANICAL
�BRENIFURNRELOCATION OF FURNACE (MECHANICAL
�BRENIFURNOV �P•El0 rURNACE > 1C-K B i U IMcCH NIC L
BREMt-UKNU INSTALLATION OF HOOO IMECHANICAL
BRENIRELOCA INIECHANICAL
BREMREPALT REPAIR/ALTER HEATING MECHANICAL
BREMVENSYSVENTILATION 5Y5TENI5 (MECHANICAL
IPPERMITFEE PLUMBNG PERMIT ISSUE PLUMBING 11
W. BPBACKFLOW
UMULTI NEW MULIFAMILY RES PLUMBING
USFD NEW SINGLEFAMILY RES PLUMBING
ATMOSPHERIC VACUUM PLUMBING
CESSPOOL CESSPOOL PLUMBING
FIXTURE PBLG FIXTURE PLUMBING
GAS GAS PIPING SYSTEM FEE PLUMBING
INTERCEP IND WASTE INTERCEPTOR PLUMBING
BPREPIPE REPIPE OF FIXTURES PLUMBING
BPSEWAGE SEWAGE DISPOSAL PLUMBING
SPSEWER SEWERS PLUMBING
BPSPRINK LAWN SPRINKLER/BACKFLO PLUMBING
BPSTORM STORMlRAIN WATER PLUMBING
BPTRAP KITCHEN TRAP PLUMBING
BPVENT ALT OF DRAIN 6 VENT PLUMBING
BPWATER INSTAWALTER WATERPIP PLUMBING
BPWHEATER WATER HEATEREN I PLUMBING
N
8PWSVCS MAIN WATER SERVICE PLUMBING
ZDEVAGREE DEVELOPMENT AGREEMENT PLANNING
ZDIRTM OIR TENT MAP PLANNING
ZFULLHR IFULLAPPL BASE- HR PLANNING
ZFULLTM FULL APPL TENT MAP PLANNING
ZFULLUP FULL APPL USE PERMIT PLANNING
ZFULLZONE FULL APPL ZONING PLANNING
ZGPAMENO GENERAL PLAN AMEND PLANNING
ZLIMAMEND LIMITED AMEND PLANNING
ZLIMTM UMITEO TENT MAP PLANNING
ZLIMUP LIMITED ADPL USE PERM[ PLANNING
ZMATEMPUP MIN AMEND TEMP USEPERM PLANNING
ZMINHIL.LEX IMINORAPPL HILL EXC PLANNING
ZMINSIGNEX IMISC SIGN EXCEPTION PLANNING
ZMINTM MINOR APP TENT MAP PLANNING
ZMINUP IMINOR APPL USE PERMIT PLANNING
ZMISCASA MISC ARCH SITE PLANNING
ZMISC IMISC TM AND UP EXT PLANNING
ZMISCFENCE MISC FENCE EXCEPTION PLANNING
ZMISCGEN MISCELLAPPL GENERAL PLANNING
ZMISCPCINT MISC PC INTERPRETATION PLANNING
ZSIGN SIGN PERMI PLANNING
ZTEMPSIGN TEMPORARY SIGN PLANNING
ZVARIANCE 11DIRECTOR VARIANCE PLANNING
• 2 oft
Krrir d 8/1099
Ory. it Applicable Fee ID 'Fee Description Fee Group
jBLDGPERMIT FEES (BUILDING
IBCONSTAX CONSTRUCTION TAX BUILDING
IBENERGY JENERGY (BUILDING O
JBENERGYADDENERGY ADD MULTI BUILDING
IBOVERTINIE INSPECTION OVERTIME JBUILUINU
BTEMPPERM TEMPORARY BLDG PERMITBUILDING
BNIITIGAT HOUSING MITIGATION FEEBUILDING
ISPLANCHK PLAN CHECK FEE BUILDING
BPLANCKADD PLAN CHECK ADD MULTI BUILDING
BPLANCKREP PLAN CHECK REPEAT FEE BUILDING
BREINSPLUI REINSPECTION FEE BUILDING
BSCBLVD SCB SPECIFIC PLAN BUILDING
SSEISMICOM SEISMIC COMMERCIAL BUILDING
BSEISMICRE SEISMIC FEE RES BUILDING
BSPECIAL SPECIAL INSPECTION BUILDING
BSWIM SWIMMING POOL BUILDING
ZADDCHG ADDRESS CHANGE BUILDING
EPERMITFEE ELEC PERMIT ISSUANCE ELECTRICAL
BELEC1000 ELEC 600V �-1000A ELECTRICAL
BELEC1001 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
BREMSIGNAD RMDL SIGNS ADD BRANCH ELECTRICAL
BREMSIGNS REMODEL SIGNS, MARQUEE ELECTRICAL
BRE THEATR THEATRICAL LGHTNG FIX ELECTRICAL
BSF&2FAM SINGLE&2 FAMILY ELECTRICAL
STEMP TEMPORARY POWER ELECTRICAL
STEMPSVCS . TEMP DIST SVCS ELECTRICAL
MPERMITFEE IMECH PERMIT ISSUANCEMECHANICAL
BAPPLOTHER OTHERAPPUANCES MECHANCAL
BBOILERI BOILER � 100,000 BTU MECHANICAL
SBOILER2 BOILER >100KTO500K BTU MECHANICAL
SBOILER3 BOILER >500 IM BTU MECHANICAL
BBOILER4 BOILER>iM TO 1.75M BTU MECHANICAL
BROILERS 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 BLDGS MECHANICAL
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INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
BUILDING PERMIT INVOICE OPERATOR: karenb
Sec: Twp: Rng: Sub: Blk: Lot:34259004.00
INVOICE DATE...... : 05/10/2000
REFERENCE ID W ...: 00050060
SITE ADDRESS ..... : 21170 CANYON OAK
SUBDIVISION .......
CITY ... . .........: CUPERTINO
IMPACT AREA ...... .
OWNER ............: O'BRIEN
ADDRESS .......... ;
CITY/STATE/ZIP ... : CUPERTINO, CA 95014
CONTRACTOR' . ......: LIC # 21563
COMPANY ... . ......: ACME 4 SONS SANITATION/ELECTRI
ADDRESS ..... .....: 1880 S. 7TH ST
CITY/STATE/ZIP ...: SAN JOSE, CA 95112
TELEPHONE . .......: (408)275-2263
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- --- --------- ------------ -----------
BTEMP P 57.50 0.00 57.50
EPERMITFEE P 35.52 0.00 35.52
--------- ------------ -----------
93.02 0.00 93.02
CE ID .. DESCRIPTION
-v ---_ VOICE ID _ . DESCRIPTION
3 UFER 304 ROUGH ELECTRICAL