99100020 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY ]{�OIOJ .C7
CITY OF CUPERTINO BUILDING-ha.ECTRICAL, rI:RMr ,00(
1—�-11
BUILDING DIVISION APPLICA-PION/PERMIT PLIIMIIING-MECHANICAL SOOO1
BUILDING PROJIL(A'IDEN'I'IFICA'1'ION
BUILDING ADDRESS SANITARY NO. AI'I'LICAI'1(IN SUIT MI'IT'AI.UAI
/a ysl rtlll AW -4-s I D �`�
OW,ryGR:S NAh1E: PHONE: CONTRACTOR'S NAME: LIC NO:
N NIC CONTROL#
RCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
L _ ,� S.�
C NTA _ PHONE: BUILDING PERMIT INFO
pir/w �(/JA/L �//P— g-7Q33 ❑ Consultant Fecs Paid by Applicant(Initial) DL ' ELECT PLUMB MUCH
l ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter Y(commencing JOB DESCRIPTION
Z with Section 7")of Division Sof the Rusincnsand Podpou...CtNe.andmylicenseis RESIDENTIAL:
'C'O PERMIT ISSUANCE
infullm.cra cf4'�Qy{{ ❑SFDWL ❑KITCHEN REMODEL
=U~ License Class-qy_' Lic.p APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIP1:
IF Z W Date-.Ve Card ❑MULTI-UNIT (]STRUCI'UkAI.
ARCHITECTS DECLARATION PANELS
ZFOyZ 1u deal dmyplim.hulll uscJ us puM1lic records MODIFICATION
REPAIR
O Z�� UPl'02WMPS El INTERIOR ❑SWIMMINGP001-
F4E]{ay Licenv,J Vrnfcsi nut 1111-1(Xx1AMI'S IMPROVEMENT []SWIMMING 1'0014
KYF', UWNER I{UILDER DECLARATION OVER 1000AMPS
El BATH REMODEL/REPAIR ❑DEMOLITION
C C ' I hereby utlinn Ihit I Door exempt frmh the Contractors Licnn.e Law for the
3 W F mRnwine reman.(Section 7031 1,13coneee and Procession'Code:Any city or county SIGNS ELECIRICAL ❑aTNER
^Oy wKcl m .. p it It construct. It P demolish, P y.dunum
ser orf t I: q ,h a,,N , thll II g daatcmcnt SPECIAL CINCUI'T/MISE.
��{} thas he is licensedp aDo die p 1 h C t h 'License Law(Chap , COMMERCIAL:
C a_OC' Tann nr :g."It SWu:70000ul 11 ve: 9 1the Baan—arldP c,o .Calc)nr 'ILMI'METER OR I'D]']!INSI'.
ty d C
thea he is cxcntpt there from DID]the basis for the alleg,tl,xcnmtion.Any
Violation or E]NEW tl1.DG/ADDITION F1 UI3M01.1'I'I(IN
^viSutlnn IlD LS by unY uppllcum l'nnt lwrinit vuhjatxtM npplicantm u civil penalty of POWER DEVICES ®+TENANT ❑FOODSERVICH
n mune than live lmnd,rd dollmrs(85(X3). IMPROVEMENT
=Q nLmowwe fthr,v,smy,onny employeeswith wages ushheir sole rnmpamnal.n. SWIMMING POOL IB.FCrIRIC
F will do the work.md taestructue,is not intendedor 011'cred fuxole(Sec.71,14.Business ❑OTHER
3 m and Professions Code:'The C..ntal Liter c Law docs not apply m an owner of OUTLET$-S ITCHES-I'IX'fUHCS
prfamt,who huild.Or improves 1lascnn,and who Aces such work himself or through
his own employees,pmvstal that such impnrvanems arc oat intended or oRewal for NEW RESID: ]AL ,EMR SG
sale.If.however,the building or inhpmvcmenh is sold within ane year ofamiction.the SO�ITFLOORAREA 8/SQFE
iter-bhilder will have the burden of pmving Thal he did not build m imams,for pa,
pow of sale.). TOTAL
0 h as owner of the aopcor,,unI exclusively contracting with licensed ennmcmrs m
onslruct the pored(Sec.7014,Business and Professions Cade:)The Contractor's Lf-
cemu law does duI apply,,,..Owner of Pmpeny who builds or improves thereon.and QTY.L,-
PLUMBING PER FEE
who contmcu for such projects with a corny,mgs)licensed pursuant 10 Curno ma's
License I.aw. PERMIT ISSUANCE
I an exempt under Sol. .R&P C for this mason
AI TF.R-BRAIN&VENT-WATTR(EA) VALUATION
Owner Dae r
WOKKER'S COMPENSATION DECLARATION lrPRCUiiLT.DEVICE !'SEDL7�
1 hereby affirm under penallyof perjury ane of the following doelamtlons:
I trove and will mnintain uCcniOcatc of Cnnsentmself-inmre for Workers Comped- RAINS-FI(JOR. OO, s]O, STORIES 'I'YPL CUNSTRUCflO
#tion,us provided for by Section}700 Of the Labor Codefar the peKo..no,of the is- Ia
k fuh hiaermit" r .DaedIl FS-ICER TRAP
worlwhicts ; II, I h
kj have and will maintain W'ark e''x Compensation Insurance.as required by Section N'L'S
3700oflhe Labor C:de.lor the Ndomaremtflac work far which this permit islssued. CG GROUP CD All
My Woderl.Cnmpen#tion Insurome anrtier and Policy nymtwr ate. J�/���
CancC .SYST - 13R4(I3A)
'fiK'rll'ICA180FENI]ONINS RAb1 WORK13RS' ,lS O��
CUMPCNSAI'IONINSUItANCP. GKEASEIINDUSTRI.WASTE 1N1'h CI? LIR BUILDING DIVISION FEES
(I'llssmtionncWno,he........tried il'tnepennit icfaore hdndreddallars(SIL GREASETRAP
CHECK FEE
ss.)
Iclarify lhal inlh,Pcrhxnwl col'Ih,waro whlchthispennit lsiFsucJ,lshull SCWI?R-SANITARY-S'FORM IiA.P00 P1'.
not unhploy any per any It 'ns et hero nuhjem m the Werkerk Conmen 13NI3RGV PiiH
,� moan Laws in Date Yj11 WNIER HPAI'EKW/VCN'1'/131.1'.CI'R CkADING i'Eli
z 0 Applicant `
NOTICE r:IL a' ..king this Canlfamtc of Bxcnmtion,you should WATER SYSTIIM/l RFAI RK, SOILS FEE
a , hccoine st t dm nsmion arm sions of the Lanor Code,you mutt
• [7.1 > I'nMwith comply with such pmms.ons or this period shall h,dccmed revoked WATER SERVICE
QPAID
C(INSTRUC'UON LENDING AGENCY NEW R13SID13N'I'IAi,PIM`W SU IN'' Date Keroip
UO 1herchy arrntt that there is a.rnsstmction lending agency car the perfumlunce ser
hr. e work for whirr Ni: rmi1 is rowed(Sec.3097,Civ.C.) TOTAL:
U. U Iw•nders Num, FI lT)1'AI,:
Lender's Addres A BU ILDING FIDi
O. I crnily that I have read this mplicution and.cam that the ubrve information is
F" N amcm.I agree mcomply with ullcily and county oNinances and sate laws relating to QTY. MECHANICAL PERMIT FEE SEISMIC FEF.
U ,Z building antstmaion.and hereby aaRoriao,Bwmmives offlik city to emer.l.the
Wxwomc spored propc0Y roti inspcetion Parp"ses' PERMIT ISSUANCE ELECTRIC FEE
(We)agree to mvc,indemnify and keep harmless the City of Cupertino against
liabilities,judgments.costs and expenses which may in any way accrue against said City ALTER OR ADD TO MITCH. PLUMBING FEE
in comequemce of the granting of this pemhit.
APPLICAN'1'11NDERSLWDS,ND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UMc-n
0,000 CFMI MECHANICALF
SOURCE REGULATIONS
0-r AIR HANDLING UNIT(OVER IRONICFM) CONSTRUCHON X
1.
Signature ufA Outer EXHAUST HOOD( I HOUSING MITIGATION FEE
can ARI IURIALS DISCLOSURE;
Will lheapplicanlnrftturc buildingaccupanl sore or handle hazardous maenal HEATING UNITM'UI
as dented by the Caper ino Municipal Code.Chuater 9.12,and the Health and Safety HEATING UNIT(OVERMMl❑TUI
Code,Sutton 25532po':
❑Yes ❑No VENTILATION FAE RUSH)) {AID Date Receipt#
Will the applicant or future dui Wingarcupanl use equipment er devices which BOILER-COMP LXhaph n I GOtit)I...rdom dr contaminants as ddined by the Bay Area Air Quality Management TlylAL:
BOILCR-COMP( ,00011'1 If)
❑Yes [:1 NO,
I ' �1thel� 1 iI sial I t: Js Ch pt 695 fib,Cal AIR CONDI'I'lONI3R ISSUANCE DATE
fort II hIIP&41'Gy( S 'i -255115 25511 d 25514.1 I 'h J that f th, NEW RhSID13N'I'IAI.MECII. $Q,PI'.
hai[diDgd t car...tlyl t ..Ahat D y " sihllyl tly th ,oPan C C/
nf1 an which nnlst •nim anon..asmamcol'u Ccnlc/ t.hPu spy
owneronmt tin Bac 'r(1'I'As: ISSUED BY: • "
OFFICE `
CITY OF CUPERTINO
;• 1 of 1 BUILDING PERMIT RECEIPT OPERATOR: christya
COPY N 1
Sec: Twp: Rng: Sub: Blk: Lot:31607043.00
DATE ISSUED....... : 10/11/1999
RECEIPT q......... : 10293
REFERENCE ID # ... : 99100020
SITE ADDRESS .....: 10951 TANTAU AV BOG 45
SUBDIVISION .......
7 CITY ...... . . .....: CUPERTINO
IMPACT AREA . . . ....
OWNER ..... .. . . . ..: HEWLETT PAC KARD CO
ADDRESS .......... :
CITY/STATE/ZIP ... : PAIR ALTO CA, 94303
RECEIVED FROM ....: TIM
CONTRACTOR .......: LIC #
COMPANY .... . .....:
ADDRESS ..........:
CITY/STATE/ZIP ... . ,
TELEPHONE ........ :
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ----------
BPERMFEE VALUATION 5,000.00 107.00 0.00 107.00 0.00
BPLANCHK PERMIT FEE 107.00 90.95 0.00 90.95 0.00
ICOM VALUATION 5,000.00 1.05 ------0- 00 -----_1_05 0.00
---___
PERMIT : 199.00 0.00 199.00 0.00
METHOD OF PAYMENT AMOUNT NUMBER
_________________ ____________ __________________
CHECK 199.00 074
'vvv--
TOTAL RECEIPT 199.00
t
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