99110122 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY qq 110
1 ZZ 2-
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - SANITARY NO. APPLICATIO UBMITTAL DATE
1 UI�r _Q
OWNER'SNAME, P • CO RAC' R'S NA
C't1 •� N/C CO TR LM
RC111TECT/ENGINEER: LIC NO: ADDR' S ❑
CO NTA T: PHGNE: BE
LLDINC PERMIT[NFO
TfyNa� 5 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
O�Z with Sedion]OW)of Division of the Business and Ptofeasions Code,and my license is
WOO PERMIT ISSUANCE. RESIDENTIAL:
FWF is full farce and effect. �nC/Il rJO ❑SFDWL ❑KITCHEN REMODEL
�UV License Clas L10.# (..7 -/I�YY APPLIANCES-RESIDENTIAL C1 ADDITION [I PLUMBING RE-PIPE
y Q a, Dam ContDECL�.tl� _
y R HITECT'S DECLARATIO t ❑MULTI-UNIT ❑STRUCTURAL
z O,�z 1 understand my plans shell be used as public records PANELS MODIFICATION
O z.+lz UP TO 2M AMPS
F--ii Licensed Professional ❑INTERIOR ❑SWIMMING POOL
� OWNER-BUILDER DECLARATION 2(11-ItiW AMPS IMPROVEMENT SWIMMING POOLS
as I hereby affirm that I am exempt from the Contmc cr's License Law for the OVER 1910 AMPS ❑BATH REMODEIJREPAIR ❑DEMOLITION
04 U following reason.(Section 7031.5,Business and Professions Code:Any city or countyw SIGNS ELECTRICAL ❑OTHER �r
1� E' which requirermit
es a pconstruct,alter,improve,demolish,m repn
air any s reco
lay-I prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC. CT
Q� that hers licensed pursuant torhepeuvisions ofrhe Conferences License Law(Chapfer9
AOa (commencing with Senum]000)of pivision3 of the Business entl Profeesloo.Code)of TEMP,METER OR POLE INST. §TITA
COMMERCIAL:
4 c 4 that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section]031.5 by any applicant for a pefmil subjects the applicant to a civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
Qnor more than five Imndred dollars($500).
❑Lasownerofthepuh h,.or my employees with wages as their sole compensation, SWIMMING POOL ELECTRICIMPROVEMENT
O will do thework,and fie Mulms is not imeadedaroffered fofsale(Sec.V044.Buainesa ❑OTHP.R
4 and Professions Code:The Contractor's License Law does not apply m an owner of OUTLETS-SWITCHES-FlXT
.. property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not iarendW or offered for NEW RESIDENTIAL ELECTS
sale.If,however,thebuilding orimprovement is sold within one yearofcompletum,the SQ.FL FLOOR AREA $/SQ.FT.
covancolocilder will have the burden of proving that he did not build or improve for pur-
pose of sale�)e 1,as r of the properly,am exclusively contracting with licensed contractors to
onsvumthe project(Seo.]1144,Business and Professions Code)The Counsel.,Ll-
nse Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMwhooontretsforouch projectsith aeommemgs)licausedpursuanttothe Cmannemrs
License Law. PERMIT ISSUANCE
❑l oro exempt under Sec. ,B&P C for Nis Caron
ALTER-DRAIN&VENT-WATER(EA) 4PWsa
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penally of perjury one of the following declarations: O
I have anJ will mainluinaCenifcate of Cnnsenno self-insure for Workers Cnmpen- DRAINS-FLOOR.ROOF,AR ,GOND STORIES TYPE CONSTRUCTION
tioo,as provided far by Section 3]00 of the Labor Code,for the performance of the
work for which this permit is rostrad. FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Insurance.as required by Section
3700 of the Labor Code,for the performance afthe work for which this Permit is issued GAS-EA.SYSTEM-1 INC.4 OUTLE IS OCCGROUPA�PN//TI
Ca Workers Compensation Insurance curve Poli Policy nalnher are GAS-EA.SYSTEM-OVER 4(EA) 371/II�
My Wo: rr'o.yJnO Policy Nn.:a bU7 ✓ �Sll
T FIOPIrTAF .X�EMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERCEPTORg
(This section need not becompleted ifthe permit is forum hundred dollars($100)
_ ' ., ;BUIE,pINtCrpNlSiIJT'PEfiS :J}
or less.) GREASETRAP PLANCHECKFEE
I certifythan in the Kirfmmance of the work for which this permit..issued,I shall SEWER-SANITARY-STORM EA.20d FT
not become subject any person in any manner so as to becomsubject to the Workers'Compen- ENERGY FEE
z ,Z cation Laws of Coliforms.Data WATER HEATER WNENTMLECfR
0 Applicant GRADING FEE
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/IREATING
abecome subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
W forthwith comply with such provisions or ibis Permit shall be deemed revoked WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Ff. PAID
V I hereby affirm thatthere is a construction lending agency for the performance of Date Receipt#
w. the work for which this permit is issued(Se,3097,Civ.CJ
Of"' Lenders Name TOTAL:
V Leader's Address TOTAL:
I terrify that 1 have read this application and state that he above information is - BUILDING FEE,
V7] correct.l agree to comply win,all city and county ordinances and state laws reaming to QTY MECHANICAL PERMIT FEE
U Z building construction,and hereby authmlu representatives of this city to enter upon the SEISMIC s
above-mentione.l PmNny for inspection purpose.,
(We)agrea to nice,indemnify sad keep barmlea PERMIT ISSUANCE the City of Cupertino against ELECTRIC F� JrS
liabilities.judgmems,costs and expenses which may in any way accred against said City ALTER OR ADDTO MECH. G EE t
consequencein of the granting of this permit
APPLICA UNDERSTANDS AND WILL COMPLY WITH LL NON-POINT piRHANDLING UNIT(TO 1g000CFM) 1999 YICRA
SOURCE ,A IONS. jj�� CONSTRUCTION
E
�(//) AIR HANDLING UNIT(OVER 10.000 CTM) CONSTRUCTTON TAX
Signature of ApplicanUCotnmemr Date EXHAUST HOOD(W/DUC) �' 91N0 M1T1G@TION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will lheapplicam or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Mon' ipul Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(a)? HEATING UNIT(OVER 100,000 BTU)
[:1 Yea No PAID -.
VENTILATION PAN(SINGLP.RESID) Date Receipt#
Will the Vdicanor furore building occupant use equipment or devices which ftDBOILER-COMP(3HP OR 100,000 BTU)
era hazardous air contaminants as defined by the Bay Area Air Quality Management TOTA
District'
54,06
Yes BOILER-COMP(OVER IOff"BTU)
❑
I have read the hazielzmaterals requirements under Chapter 6.95 of the Cali- All CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 25505,25533 and 25534.1 underslund that if the NEW RESIDENTIAL MECH. SQ.EL
buildin ce t N
not currently have a tenant, it is my responsibility to notify the occupant
ofth qtr' t mm prlorrolsmaneeofa Cerr m o
Owaer or atuhnrized achy ar TOTAL: ISSUED BY: /
OFFICE `
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
BUILDING PERMIT INVOICE OPERATOR: christya
Sec: Twp: Rng: Sub: Blk: Lot:35617049.00
INVOICE DATE......: 11/19/1999
REFERENCE ID # ...: 99110122
SITE ADDRESS .....: 21756 COLLINGSWORTH ST
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: SOLIZ GUIDO L AND SUSAN C
ADDRESS ..........:
CITY/STATE/ZIP ...: CUPERTINO CA, 95014-4709
CONTRACTOR ....... : TRILLO, KELLY LIC # 4269
COMPANY .......... : ATLAS HEATING
ADDRESS ..........: 155 SAN LAZARO AVE
CITY/STATE/ZIP ...: SUNNYVALE, CA 94086
TELEPHONE ........: (408)739-0516
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
BPVENT P 8.33 0.00 8.33
BREMAIRHM P 8.33 0.00 8.33
BREMHEAT P 6.11 0.00 6.11 '
BREW41SC P 25.53 0.00 25.53
EPERMITFEE P 35.52 0.00 35.52
WITFEE P 35.52 0.00 35.52
1ITFEE P 35.52 0.00 35.52
154.86 0.00 154.86
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
........ ..............:............. ........ ............................
204 UNDERFLOOR FRAME 301 ROUGH PLUMBING
303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL 514 FINAL PUBLIC WORKS
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