99090148 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI I'Y OF CUPERTINO BUILDING-ELECTRICAL PER fl O.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE,
O :R'S 'AME: PHONE: CONTRACTOR'S ME: LIC NO:
NIC CONTROL#
"G"17NEffi�R(ENGINEER; LIC N( AIIII-14 ❑
/ Sx/ fi
:ak PHONE: BUILDING PERMIT INFO
/IbM" a 9 J-7 /� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELE PLUMB MECH
❑ ❑
LICENSED CONTRACTOR'S DECLARATIONQTY ELECTRIC PERMIT FEEeby of irm Thal 1 am licensed under proi:in,of Chapmr 9(xnmmeneths JOB DESCRIPTION
9001Divinir�n 3ofhe Bn,inex,and Pmfe,aion,Crde,addmy hemf,eRESIDENTIAL:
and e t ,,((��a / PERMIT ISSUANCE
s �e"T.icp 3 �� / ❑SPOWL ❑KITCHEN REMODEL
Gmoactm 9�B APPLIANCE,$-RESIDGNTIAL ❑ADDITION E)PLUMBING RE-PIPE
A CHU'ECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
F h L 1 understand my plans shall be used as public records PANELS MODIFICATION
ZO z.N. UP TO 200AMPS
EPAIR
W Licensed Professional ❑INTERIOR ❑SWIMMINGNEY POOL
Q F- OWNER-BUILDER DECLARATIONis: 201-1000AMPS IMPROVEMENT SWIMMING POOLS
Q1 hereby affirm that I am exempt from the Comructor'c License Law for the OVER["AMPS ❑BATH REMODEf/REPAIR DEMOLITION
3 LLH following reason.(Section 7031.5.Business and Professions C de:Any city or county SIGNS ELECTRICAL ❑OTHER
rq which mynan,n permit to aondn o.cher.improve,demolish,or repair any s r'nme
F_LL'04 prior m rR isuadcs,a[wreyulhe'do.Pn [icam for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
f } that he is licensed pnmaano the pro inions oContractors
f the License Law(Chapter 9
COMMERCIAL:
11
9=<0 (conencingwon Seaton7
nniW0)nf Division 3 of he B usme,s tmJ Podions Code)or I'EMP.METER OR POLE INST.
a a c C that he is a<mpt therefrom and the havis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
K r^a Section 7031.5 by any applicant for a permit object,theapplicanl us a civil Penally of POWER DEVICES
1>,`..� [1 TENANT ❑FOOD SERVICE
maintain,than five hundred hall...(SSW). IMPROVEMENT
=Q ❑1,as owner of the properly,or my employees with wage,az their sole compenzuriun, SWIMMING POOL ELECTRIC
F.. wi lldd the wurk,and thesmcwru is not mended...offend liusale(Sea 70,14,Bexinex ❑OTHER
al 3 m and Profecainnv Code:'The Contractors License law does not apply to anowner of OUTLETS-SWITCHES-FIXTURES
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 ELECTR SQ FT.
zalc.If,however,the building or improvement is sold within one yea ofcomplenon,the — FLOOR AREA SISQ.FT.
ownerbuilder will have the burden of proving that he did not Ifuild or improve for pur- 7
pose of sale.).
1.as owner of the property,sm exclusively contracting with licensed contractors to TOTAL:
construct the project(Sec.7044,Business and Pmfcscionz Code:)The Convector',Lt-
.se law does not apply to an owner of progeny who builds or improves thereon.and QTY PLUMBING PERMIT FEE
who contacts forzuch project with a ventmchms)licensed pursuant to the Contractors
License Law, PERMIT ISSUANCE
l am exempt under Sec. ,B&P C for Nis reason
Dale ALTER-DRAIN&VENT-WATER(EA) VALUATION
r
w x WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE
Iherchyaflinn underpered,oft,rdna meofthe following dedarmions:40 � QQ
(] [have and will maintain a Cemficate of Conxenued
o self-insure for Worker s Comp - DRAINS-FLOOR.ROOF.AR STORIES TYPe CONSTRUCTION
ration,as provided for by Section 37M of the labor Com
Cock,for the perforance of the
for which this IMmfil is Issued. FIXTURES-PER TRAP
w I have and will nminuin Worker's Compensation Inmanee,ac«yoired by Sen int
W of the labor Code,for the petfurmanceofthe work for whichthispermit is iomuJ GAS-EA.SYSTEM- INC.4 OUTLETS OCG.GROUP q pPNb
My W, ke Cuhn'toution In airier I Policy number G
Carrier: ,n�S/y{ /. earw/� he No. 1� GAS-EA.SYSTEM-OVER 4(EA)
7Ctxl IN AH'OphXLMI ION IROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
(This section need not be completW if the permit is!orad handout dollars($Ilk) BUILDING DIVISION FEES
or Iccx) GREASE']RAP PLANCHECK FEE
1 ccnify that in the any Performance r ofthe i work for which this permit is ori'Cr l shall
not employ any Person in an SEWER-SANITARY-STORM[A.iW FT.
P y manner so as of become mhjeel to the Workeri Cnmpen- ENERGY FEEp A,fi Laws ofCulinfmia.DateWATER HEATER WNENTELECIR
wt
Z A pltcunt GRADING LLE
yNOTICE TO APPLICANT:If.of sr making this Cenificam of Exemption,you should WATER SYSTHM(TREATING
heconte subject to the Workers Compensation provisions of the Labor Cale,you most SOILS FEE
four lth comply with such provi,hime or this permit,hall he deemed revoked. WATER SERVICE '--
1 i
Uz Heathen,is.OONLENDINGAGENCY NEW RE,SIDF,NI'IAL PLMB. SQ.Er. PAID
U thereby affimf than then isarnnmmcuion lending agency for performance of �II U_ReceiplN LJ II 1
the work for which IM1is permit ix hand[Suc.3097,Civ.CJ
C) U Lender:,Name ti� ��
W Lender's Addre„ TOTAL: W
G I certify that I have read this application and state that the above iolarand on is BUILDIN ere SE►' u a IJ,+
to mtrect.l agree or comply with all city and county noblemen and ante laws relating to QTry. MECHANICAL PERMIT I FEE I
°V Z buildingeomwction.and hereby authorize rcpresentnlives ofthiscily to enmruponlhe SEISMIC�131E,
above i(we)a ere to saveroperty fnr emnify an keep hs. PERMIT ISSUANCE
IW'e7 agree to,ave,indemnify and kap hamiless the City of Cupertino agaivt ELECfRlC FEE
Imbilitics,judgmens,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in cvxi".cna of the granting of thi,permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(10 W.000CFM)
SOURCE REGUL1An9'IONS. MECHANICAL FEE
/Ls.-.� r/a _- AIR HANDLING UNIT(OVER 10,w CPM) CONSTRUCTION TAX
S�ndla IAppreenVCum tlor ae EXHAUST HOOD(W'MUCf) HOUSING MITIGATION FEE
HAPARDOUS MATERIALS DISCLOSURE
Will the applicant nr future building"cuupam store or handle bunasJou,material HEATING UNI'I'(TD IN)OPY,BT U)
us defined by the Cupcnino Municipal Cade,Chader 9.12,and the Health and Safety
Code,Section 25522(a):' HEATING UNIT(OVER 100,000 BTU)
[:1 Ye, ElNo
VENTILATION FAN(SINGLE RFSID) PAID pare Receipt#
Will the applicant in nts as
building by the B ace u Air em or doime which
nrh:varJouc air ammminanumJdined hY the Buy Arca Nr Quality Managemcnl BOILER-COMP(JHP OR 100,000 BTU)
Di,ttct^ Tor k
❑Ycx No BOILeR-COMP(OVF,R I00IMNI BTU)
I have read the h aallous matedolx requirements under Chapter fi 95 of the Cali- AIR CONDITIONER ISSUANCE DATE
loon.Health&Safety Code,Section,25505.25533 and 25534.1 understand that d the F NEW RESIDENTIAL MECH. SQ.ET.
building doe,not commonly have xh,m ,that it is my responsibility tonoofy thea'cupan 9'— ) �
Oyr
a[////th//////e rey ffttsou �lhicbm the met ptonnissuaneu nfn Ccnificnte fa panty. (/ - G— ( C
IM1a rr ud E"end �QP
g TOTAL ISSUED BY:
OFFICE
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
. BUILDING PERMIT INVOICE OPERATOR: karenb
Sec: Twp: Rng: Sub: Blk: Lot:362070II.00
INVOICE DATE. . . . .. : 09/27/1999
REFERENCE ID n . . . : 99090148
SITE ADDRESS . . . . . : 1134 STAFFORD DR -
SUBDIVISION ..... ..
CITYCUPERTINO
. . ...... . . . . . .
IMPACT AREA ..... . .
OWNER ......... . ..: WOLNOWSKY HOWARD E AND LOUISE
ADDRESS ...... . . . .:
CITY/STATE/ZIP . ..: CUPERTINO CA,. CA 95014-4912
CONTRACTOR .... . . . : RANDO, JOE LIC N 8050
COMPANY A A A FURNACE COMPANY
ADDRESS . . ........ : 1712 STONE AVE
CITY/STATE/ZIP ... : SAN JOSE, CA 95125
TELEPHONE . . . . . . .. : (400)293-4717
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- --- --------- ------------ -----------
BREMAIRHAN P 8.33 0.00 8.33
BREMMISC P 25.53 0.00 25.53
EPERMITFEE P 35.52 0.00 35.52
MPERMITFEE P 35.52 0.00 35.52
--------- ------------ -----------
104.90 0.00 104.90
INE ID DESCRIPTION VOICE ID DESCRIPTION
--------------=.... ... ................-...........
303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL
505 FINAL ELECTRICAL 508 FINAL MECHANICAL
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