99080195 (2) _ APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY q 61O a C0 1 01_s—
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPIACATION/PE.RMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWN SNNLA�� p PHONE: CO CPOR'SN MF:'. LIC NO:
• ARCH LTvI['.NGI R:�I V PH
is j AD RGgS: } ' NIC CONTROLM
ED
I m r..
JNTACT: PHONE: `BUILDING PERMIT[NFU
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB _ ME❑CH
'le
LICENSED CONTRACTOR'S DF.CL.A AI'ION QTY ' ELECTRIC PERMIT FEF.
I hereby affirm that 1 am licensed under provisions of Chatter 9(commencing JOB DESCRIPTION
wo, with Seetiaa70f10)of Division 3ofthe Bminesa:ud PrnresomiC de,andmy license is RESIDENTIAL,
DENTIAL,
~W� in full force end e0[yt. !'� PERMIT ISSUANCE ❑SFDWL ❑KITCHEN REMODEL
�UV license Class\•. Lic •] APPLIANCES-RESIDENTIAL. ❑ADDITION El PLUMBING RE-PIPE
vFiQ6 11atcs'aSYIiAc commaor_ It1�
E-O y ARCHITECTS DECLARkrbbW PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O rrn 7. I understand my plans shall he used as public records MODIFICATION
OZ-1 UPT02MAMPS ❑INTERIOR ❑CHIMNEY REPAIR
Feat Licensed Professional 201-1100AMPS IMPROVEMENT
�W ; OWNER-BUILDER DECLARATION ❑DEMOLITIONPOOLS
C Q I hereby a01mt that I am exempt from the Contractor's License Law for the OVER IOf10AMP5 El BATH REMODEIIREPAIR DEMOLITION
3 a U following reason.(Section 1031.5,Business and Professions Code:Any city ornmmY SIGNS ELECTRICAL ❑OTHER
LL which requires a permit to construct,alter improve,demolish,or repot any net..
t: Poetry its issuance,also requires theappfirmaforsuch permit to file."Iyord'anconent SPECIALCIRCUIT/MISC. C
} that he is licensed puromm to the pmvisions of the Contractors License Law(Chapter 9
CSO (commencing with Section 9000)of Division 3 ofthe Business unit Professions Come)or TEMP.METER OR POLE INST. COMMERCIAL:
a X e e thm he is exempt Ncrtfrnm end me basis for me alleged exemption Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
WMm Section 7031.5 by any applicantfor a permit subjects the applicant u a civil penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE
t mom than five hundred dollara85 W).
FRQ ❑ has owner of the pmpcny,or my employees with wages as theinnle compcnsetion. SWIMMING POOL ELECTRIC IMPROVEMENT
fir will do the work,and thotmmure jams nlendedor offered fn...le(Sea.70 ,Bminess El OT1WR
W--m and Professions Calc:The Cmdocmrs License law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
ts'3 property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELF.CTR SQ PT. N -
side,If,however.the building or improvement is sold within one year mcompletion,the /�SQ.FT FLOOR AREA $/SQ.ET.
owner-huilder will have the burden of proving that he did not timidity improve for par- ///
pose of ale.).
❑ 1,as owner of the property,am exclusively oonwcting with licensed continuous to TOTAL:
construct me project(Sec.7041,Business and Profession,Cwlep The-110 ler s L
se Law does not apply to an owner of property who builds or improves thereon.and QTY' PLUMBING PERMIT FEE
who contracts far such projects with a connotations)licensed pursuant to the Contractor's
Liceme Law. PERMIT ISSUANCE
1 am exempt under Sec. ,B&P C for this reason
Owner Date ALTER-DRAIN&VENT-WATER HQU VALUATION
. WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent o self-insure for Worker's Cooper- DRAINS-FLOOR,ROOF,AREA.COND. STORIES 'TYPECONS'I'RUCTION
rkas provided for by Section 37M of the Lahr Code,forme performance of the
Inr which this permit ix issued FIXTURES-PCR TRAP
I have and will maintain Workers Compensation Insuranceas required by Section
37M ofthe labor Cale,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.A OUTLETS OCC.GROUP --
My Workers Compenstion Insurance carrier and Policy number arc: 'V
Cameo Policy No.: GAS-EA.SYSTEMOVER)(EA) h
CERTIFICATE OF EXEMPTION FROM WORKERS' V
COMPENSATION INSURANCE: GREASE/INDUSTRL WASTE INTERCEPTOR
BUDDING DIVISION FENS
('this section neeJ not he completed if the permit is forone hundred Jolters(g 100) GREASE TRAP
tar less) PLANCHP.CK FEE
I ecrtifythm in the perfrrommeeofthe work for which this permit is issued,[shall SEWER-SANITARY-STORM EA.200 FT
not employ any person in any manner so as to hecomc.subject to th Workers'
Compen- ENERGY FEE
Z
sation laws of yfo a.D
zO Applicant �la.�rt'� - _ WATER HEATER WNFNT/ELECTR GRADING FEE
Vj NOTICE TO APPLICANT:If,attar making this Cenifica TExemption,you should WATER SY.STEM/IREATING SOILS FEE
abecome subject to the Worker's Compensation provisions of the Labor Code,you must
ILL Forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
� z CONSTRUCTION LENDING AGENCY NEW RESIDENT'IALPLMB. SQ.FT. PAID
V 0 l hereby alfiw that is a connmetion lending agency for the performance of Data R etpts
U. the work for which this permit is issued(Sec.3097,Civ.C.)
O Uloader's Name TOTAL:
tour's Address TOTAL:
1 terrify that I have read this application and stale that the above information is BUILDING FEE
LtN correct lagrce to comply win,all city and county ordinances and tam laws relmingm QTY, MECHANICAL PERMIT FEE
V z building construction.and hereby authorize repremotmives of this city to enter upon the - SEISMIC FEE
ahov>rnetnioned property for inspection purposes.
(We)agree to save,indemnify and keep hamdess the City of Cupertino against PERMIT ISSUANCE ELECTRIC TEF.
lin ities.judgmrng casuandexpcnseswhich may in any way seem,against said City ALTERORADDTOMECH.
ins sequenm of the gnunin,of this prmit. PLUMBING FEE
APIACANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'TGO 10,000 CFM)
SO iCE REGULATIONS. p MECHANICAL FEE
a,1l A AIR HANDLING UNIT(OVER 10(X0 CFM) CONSTRUCTION TAX
Si no to pylic HAZARDOUS
Datc-_I EXHAUST HOOD(WMUCO HOUSING MITIGATION FEE
HALARI�US MATERIALS DISCLOSURE
Willthe ytepCulamni future building occupantstore r9,12.handle Health
and Safety
HEATING UNIT(1U IW,OIXI BTU)
as defined io the Cupertino Municipal Code.Chapter 9.72,and the Health and Safety
Coda Section 25532(.)7 HEATING UNIT(OVER 100,(00 BTU)
El Yes 7 N VENTILATION FAN I$INGLE RFSID) PAID
. Will the a t Brant or furore building t use equipment or devices which Date Receipt M
IP 6bytheBaitBOILER-COMP(3HPOR 100,0101 BTU)
emit havedous air contaminants as Jefinod by the Bay Arca Air Quality Management TOTAL'
'strict? BOILER-COMP(OVER 100.000111110100.000111110❑Yes ON.
I have read Ore hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
(omia Heald&Safety Code,Sections 25505,25513 and 2551G.I urt4mend Nat if the NEW RESIDENTIAL MECH. SQ.Ff. ^ 9
"am"8 dies notnmendy haveatenant,rhot,,is my responsibility to notify the occupant -2— /
of th require is watch must 6e met pilar te issuance of a Ce Ream
of Givers try. II
0 sammthorizedagem Dam TOTAL: ISSUEDBY:
OFFICE
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
BUILDING PERMIT INVOICE OPERATOR: christya
Sec: Twp: Rng: Sub: Elk: Lot:35608003.00
INVOICE DATE......: 08/26/1999
REFERENCE ID # ...: 99080195
SITE ADDRESS .....: 10796 LINDA VISTA DR
SUBDIVISION ...... .
CITY ............. : CUPERTINO
IMPACT AREA .......
OWNER ............: NELSON KELVIN R
ADDRESS .... . . ....:
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4021
CONTRACTOR ....... : LIC #
COMPANY ..........:
ADDRESS ..........:
CITY/STATE/ZIP ...
TELEPHONE .... . . ..:
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
--- --------- ------------ -----------
BPGAS P 4.44 0.00 4.44
BPLBGFEE 35.52 0.00 35.52
39.96 0.00 39.96
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
........ ............................ ........ ............................
SEWER & WATER 202 UNDERFLOOR PLUMBING
ROUGH PLUMBING 302 TUB & OR SHOWER
FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
•
CITY OF CUPERTINO
Item 1 of 1 BUILDING PERMIT RECEIPT OPERATOR: yvonnek
COPY # 1
Sec: Twp: RnB: Sub: Blk: LOt:3560B003.00
DATE ISSUED....... : 08/27/1999
RECEIPT $......... : 9914
REFERENCE ID # ... : 99080195
SITE ADDRESS .....: 10796 LINDA VISTA DR
SUBDIVISION .......
CITY. ..... . ... . . . . : CUPERTINO
IMPACT AREA . . . . .. .
OWNER ....... .. ... : NELSON KELVIN R
ADDRESS .......... :
CITY/STATE/ZIP ... : CUPERTINO CA, CA 95014-4021 -
RECEIVED FROM ....: TIM
CONTRACTOR .......: LIC
COMPANY ... . . . . . . . :
ADDRESS .... . . .. . . :
CITY/STATE/ZIP . .. .
TELEPHONE '........ :
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW SAL
__________ ____ ______ ___
BPGAS OULETS 1.00 4.44 0.00 4.44 0.00
PPERMITFEE FLAT RATE 1.00 35.52 0.00 35.52 0.00
TOTAL PERMIT 39.96 0.00 39.96 0.00
10 OF PAYMENT AMOUNT NUMBER
CASH 39.96
TOTAL RECEIPT 39.96
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
........ ............................ ........ ............................
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 302 TUB & OR SHOWER
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING