00010024 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 0 1V 6
CITY OF CUPERTINO BUILDING-ELECTRICAI. PERMIT NO.
BUILDINd DIVISION AFPI,ICA'PION/1'RRMIT rhumnwc-MEcuAnTFIC ea,arsl
BUILDING PROJECT IFIEN'1'IF'ICA'1'IUN
1�'I
131,LDING ADDRESS:
gANI'I'ARY NO. APPLI I)ONSUBMHTALDxrc
WNER'S A 1E: PHONE: RACR)R'S NAM-' CA, IDC NO:
NIC CONTROL#
, Clam] I
RCI{ITELI'IIiNGINI!I!N: LIC NO: A 'SS: r`81
CONTACT PHONE: BUILUING PERMITINFO
❑ Consultant Fucs Paid by Applicant(Initial) BLI]1y_ ELECT PLUMB MP.CH-
El
LICENSED CONI'RACTOR:S DECLARATION QTY ELECTRIC PERMIT FEE rL'[I�g LrJ�/
I hereby mrmt m:n I am licensed coder mvi,i co of chapter 9(commencing JOB DESCRIPTION
pZ with Division 3 none Reline, r...c,00a,Cde,md.gy license:. RESIDENTIAL
t 9 `_p� 1'ENMIT ISSUANCE REMODEL
F 1yB mfull forceendedea. �S�31SX ❑SFDWI. ❑ DCHEN
QUU License Clautl V hic.N 11-� APPLIANCES-RESIDENTIAL ❑ADDITION CI PLUMBING,RE-PII'li
yQ4 Date Cntm ❑MULTI-UNIT El STRUCTURAL.
ARCHITECT'S DECLARATION PANELS MODIFICA'UON
Z Q N Z l undeasmnd my plan%.ahall M used as public records UY TO 200 AMI'$
OZ�O [I INTERIOR ❑CHIMNEY REPAIR
Fat�F� Licemed Prnce"ioml 201-IONAMP$ Ih1PROVIiMENT ❑SWIA1s1ING POLLS
�yE J OWNER-BUILDER DECLARATION OVER TWO AMPS O,BAT'H REMODELg4 PAIR ❑DEMOLITION
C Q 1 hereby affirm that I am exempt lions the Contfacmr'x License I.aw for the All
rWROTH[R "�M`1 Ito A+ _
X6 U following among.Section 7031.5.Business and Profe,slom Gude:Any city or county SIGNS ELECTRICAL
W 3 m i- which requires a permit a construct,altar improve.demolish.or repair any stacturc
WQ statement
t lw ..cls til rpli ' tf cap mitt 11signedClopwrit SPECIAL CIRCUIT/MISC.
'S Y than I ,'pars tl til p 'xm: ❑I G I mor L LwlChWI IW C, Iro e g 'til Sect ]ofq) fU isi 3 fm B ace JP fe:: rot Cud011 TEMI'h1E11:R OR POLE INST.that he is exempt therefrom and me basis far the alleged exemption.Any violation of DDI'TION ❑FOODDEMO.l1ION
Section 01015 byany applicant fora pcomiwclove Ndreapp6cont macivil penalty of POWER DEVICES ❑FOODSERVICE
t more than live hundred dollars($50). NT❑Lesawner ml thepropenle,anycmplmyve,with wagctm tlteiranlc compensation, SWIMMINGIY)OLF:LECIRICwill do the work,attd theHonore is nm intended ormRered fm sale Sce.T]H,Business OUTLETS-SWITCHF_S-FlXTURIiS
am and Pro It,,ns Cute:The Cammno...License Law dines not apply m an owner mfmo,vroy who builds ser improves tcnoj and who ial; m n work hiluded o f or thtnugM1
his own employees,provided tram such tent is sold w am nm:year od m olfered for Nf!W RESIDI!N'TIAL EL1!CTR SQ PC..ole.If.however,mM1e building nrimpmvcntcm is sold wimin one year ofnampinian.the OOIt AREA 91SQ.IT.
owner-builder will have the burden of proving that he did not build of impmvm for put-
potc of sole.), TOTAL
❑ 1,as owner of me pmpdy,am exclusively contracting with licensed coat ic.c.1m
consumer me project See.]IW.Business and Professions Code:)The Cormicam's Li-
cense law does not apply to an owner of property who builds or improves mhearn,and QTY PLUMBING PERMIT FEE
will)contracts forsuch projeas with a umtecunl N)licensed Furman to the Contactors
LlccnNe Inw. PERMIT ISSUANCE
❑lameaomptander Sw, ,B&PCI'ormisreasm
ALTER-DRAIN&VENT-WATER(EA) VALUAJ'ION
)wrier Date
WORKER'S COMPENSATION DECLARATION HACK FLOW PROTECT'.DEVICE
��,,]]// thereby affirm under petmltyof perjury one of the folltlwing decletin
mns:
SuA`
have
ve and will maintain a Certifico¢of Consent mself-insum for Workers Cumpcn- DRAINS-FLOOR.ROOF,AREA.COND. STORIES '1'YPIi CUNSI'RUCf10N
provided for by Section 3701 of the Iaor Coda for the performance of the
wnrk for whlcb this pram I'i'llati PI%TURES-1'[R TRAP
❑I have and will..main Workers Compensation Insurance.as required by Section
37Ml ofthe lnor Cale,for the performance oftnc work far which oris permit is issued, GAS-EA.SYSTEM-1 INC.J OUT LL'TS OCC.GROUT' G AIYy/
My Worker's Compensation Insurance carrier and Poli JyIIa1 9a� //,I f-
C;l,rice policy N� 1- M�C1�r1'i��Y GAS
-EA.SYSTEM1I-OVF,R4(EA) SD
CERTIFICATE OF EXEMPT]ON PROM WORKERSGREASH/INDUSTRL WAS TE TO
COMPENSATION INSURANCEBUILUING DIVISION FEES
(Bus.wction need nm be completed time permit is formic hundred dollars(SIM) GREASETRAP PLANCHECK FEF.
lest.)
I cemily that untie IT ancicc of me work list whielnhi,permit is issued.lehal l SEWER-SANITARY-S1 ORM HA.200 FI'.
notemploy any GpeIrni[�m(pinq any mannermm-y,{tiynpTe ah,cvt o the Worker,'Coroner- 1!NERGVIgili
O z .Nation laws of XJi/� WATER HEATER WNENDELECTR GRADING FEE
rZa Applwmt X�
y NOTICE TO APPLfCAN"P.If,after nmklng tills Cemlicam of Ixemption.You should WATER SYSTEM/TREATIN 1 SOILS FID!
bromic Nuhjcn tome Worker's Corissa...mas provi.Ni...of the LaMn Code,Yeo must
Q
lonhathcomply with such provisions ormitPermit shall beJeemedrevoked. WATER SERVICE 1
GONSTRUCIIONLENDINGAGENCY NEW RESIUIiNT1A1.PLMB. SQ.PL PSIUl Da¢ \N Receipt%
U 0 l hereby affinnthauhem is.I.mwmion le"dmgugency for the performance of yi� II _. I
— the work far which this permit is issued(See.3097,Civ.C) Ijiq�l 'DOTAL
Lenders Name t
Leaders,Addoex, TITI'AL'.
1 comity that I have read this application and smr,that the move Information Is B�ILDINC PEE.
.F. 0 maces l agree a comply with allcity and county ominznms and sine laws reform,In QTY. MECHANICAL PERMIT FEE Lismic FEE!
U Z building construction,and hereby authorize representatives ofthis city matnerupmn the '
nose-mentioned property for inspection purposes. PERMIT ISSUANCE IrIfCI'RIC FEE_
(We)agree no save,tad,n lily and keep harmless the City of Culmina against - -
liuhilimies.judgments,coon and expenses which may in any way accrue against said City ALTER OR ADDTO MECH. PLUMBING FEE
in asequence of the grating of this .it.
APPLICAN"1'UNDERS"JANES AND WILL COMPLY N'I'TH ALL NON-POINT' AIR HANDLING UNIT(TO 10.010 CFM) MECHANICAL FEL!
$Dim 1RI!(1 IONS.^ ^
ABY \ III ^Il AIR HANDLING UNI'I'(OVpR 10,000 CFM) CONS'JRUCT'ON'ITX
Signeer`emf Applicant/Comnmm `Y Date EX AUSTHOOD(WIDUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE 1
Will the applicant of future buildto,tweemat om or handle hamrtlous mwcriu HEATING Cost I LTO 100,000 B"TUI
IN defind by the CuNnine,Municipal Cde,Chapter 9.12.and the Health and Safety TH ATJNG UNIT(OVER 100.010 BTU)
Cde,Section 25532(al'(
[]Yet V ENTILATION FA N(SINGLE NESID) PAID -
Dae Rcaipt p
Will the applicants or future building occupant use aluipment or devices which BOILER-COMPLIHPOR 1(1f 000 BTU)
mit brumdaus air contaminants an dcGned by the Bay Area Air Quality Maaugement 'DOTAL: 6
District? � HOILER-COMP(OVER 100.(100 BTU)
❑Yc.N
I have read the bazvdous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE UA'TF,
fomia Halm&Safety Cde,$cainne 25505,25533 and 255]11 understand that it the NEW RESIUENTIAI.MECH. SQ.FT. �O Q
buildingdmsnmctmeral,Lowe award,mm it is my responsibility 6)ratify thetectmant (9 C/
f nR which fnaMmm pro,,to ixsuancc n(o Cc'fyl;'111 CcupnncY.
Owmal taco — 110
TOTAL]
ISSUI!U BY:
OFFICE
INVOIG'E INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
• BUILDING PERMIT INVOICE OPERATOR: christya
Sec: Twp: RnB: Sub: Blk: Lot:31636050.00
INVOICE DATE... . ..: 01/06/2000
REFERENCE ID # . . . : 00010024
SITE ADDRESS .....: 10824 NORTHVIEW SQ
SUBDIVISION .......
CITY ....... . .....: CUPERTINO
IMPACT AREA .......
OWNER ......... . . . : HEMA CHAMNG
ADDRESS ....... . ..:
CITY/STATE/ZIP ... : CUPERTINO CA, CA 95014-0542
CONTRACTOR ....... : SMITH, BYRON E LIC # 21144
COMPANY . .........: A PERFECT CLIMATE
ADDRESS . ......... : 4799 LYRIE LN
CITY/STATE/ZIP ... : SAN JOSE, CA 95111
TELEPHONE ........ : 4082269990
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- -__ ------------ _----______
BREMHEAT P 6.11 0.00 6.11
MPERMITFEE P 35.52 0.00 35.52
--------- ------------ -----------
41.63 0.00 41.63
DSCRIPTION
= ID ---_ -- DESCRIPTION ........
VOICE ID ==.......E..................
204 UNDERFLOOR FRAME 301 ROUGH PLUMBING
303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL
505 FINAL ELECTRICAL 507 FINAL PLUPIDING
508 FINAL MECHANICAL 514 FINAL PUBLIC WORKS
•