99090129 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
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CSTYDERTINO BUILDING-ELFCTRICpL
NCUPVISION APPLICATIONPERMIT PLUMBING-MECHANICAL
VICA
BUILDING PROJECT IDENTIFICATION
BUILD2NG ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
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OWNER'SME: PHONE: CO ACfOR'SNAME: LIC NO:
is
�✓ NIC CONTROL"CHWPR � /FA'GINEIR: LCNO: ADDRESS: Lai 165 ❑
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CONTACT: PHONE: B LDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BL ELECT PLUMB MECH
El EJ 1:1
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
qI hereny.cert.th:n 1 am licensed tinder provisions of Chapter 9 ocomme...g JOB DESCRIPTION
WCZO with Section 7000)oIDivision 3 ifthe Btamassand Professions Code,and my license is PERMIT ISSUANCE RESIDENTIAL,
F00 full Interred cllicw 6sy7� ❑SFDWL ❑KITCHEN REMODEL
Nu License Class /R Lia.p H gpp1,1ANCE5-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE d Date Contractor &AA ��e.
ARC1I1'TECT'S DECLARATION ❑MULTI-UNR E3 STRUCTURAL
F m PANELS
,Z MODIFICATION
O O y Z 1 undreamed my Ions shall are used as public recoNs
py�n WM c, UP TO 2W AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Licensed Profess mai 201-HO AMPS AL IMPROVEMENT C]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1003AMPS ❑p BATH REMODEUREPAIR ❑DEMOLITION
C C Q 1 hereby u0irm that 1 am exempt from the Contractors License Low for the
�3WF following reason(Scetion]OJLS.Business and Professions Codc:Any city 9r county SIGNS ELECTRICAL g��µ
y which requires a permit to construct,alter,improve,demolish,or repair any structure X /b s� n PLEA
E"LL�g prior to its i....a.six."aie,Ne applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
fly that he is licensed piromand to the Provisions of Ne Contractors License Law(Chapter 9
Wno (commencing with Section](MM))of Division 3 ofthe Business and Professions Circ)or TEMP.METER OR POLE IN ST. COMMERCIAL
Wa yy fast he is exempt therefrom and the basis for fire alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W^N Section 7031.5 by any applicant for a permit subjects the applicantto a civil Penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
net mem then five hundred dollars(ESm).
Y IMPROVEMENT
Q ❑1,as owner ofthe property,or my employees with wages as their sole tompensaion, 5 l. IL
�r�-
will do the work,and the suunue is not amended oroffetW forsole(See 11 4,Business ER
13 and Professions Code:The Court s License Law does not apply to an mune,of O I
property who huilds nr improves thereon,end who does such work himself,.through
his own employees,provided that such improvements are not intended or offered for NEW RP IDENTIAL ELECTR SQ PT.
sale.If.however.the building or improvement is sold within one year nfcompletion,the QTFT.'PLf1DR��. LSQ.FI'.
, ervbuilder will have the harden of proving that he did not build or improve fir pur- Q f
r,r rr,oR,). - - D L
❑ 1,us owner or arc property,am exclusively contracting with licensed connectors m, TA D
gli
construct are pmjcat(Sea.7044,Bmincss sad Pateasbis Cidr)no Contractors LI-
cons,Law does not apply it)anowner atproperty who builds orimproves Intenn.and QTY. F SEP 2 1 19 9
who connects fir such projects with a conrracmr(s)licensed pursuant Conten
to",the Cimm's
License L.W. M
I am exempt under Sec. .B&P C for this reason
ALTER-DRAIN&VENT-WATER 1 8y VALUATION
Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hand w ithrn under penalty of perjury one of the fallowing declarations:Co
❑on,as and will Cerfificate of Co Labor Care,
ehe Workersce of the DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
scion,as provided for mi Section 3]00 of the Labor Cade,for the performance of the
rk for which this permitisissued. Insurance, FIXTURES-PER TRAP
/rr�I1 haveamt willmaintain he teff .me oftte w k arwhich
dr i S...ion
-3]00of thel C. Ctme,fanhsurancmmnceofN Policy or��pwppphiypct��h this per�mfi.t is``issued. GAS-G.SYSTEM-I INC.0OUTLETS OCC GROUP e3 � i f
C�Waket_SCotgpcnsvyon tree ceriePof YNaYLj, 1 %1 GAS-EA.SYSTEM-OVER DAi '`/—J�'
SS''t�OOC.•EERR__TIFIFFII�r EXEMPTION FROM WORKERS' el
.. COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
BUB.DING DIVISION FEES
IThissection modern becnmpleted ifthe Permit is furore hundred d.11.1EI01B GREASETRAP
or less) PLANCHECK FEE
I ccnify than in the Federation,offhc work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person In any manner so as a became subject m the Workers'Compen. ENERGY FEE
'Q ,z cation Lows of Culbarnin.Dole WATER HEATER WNENT/EI.P.CTR
O Applicant GRADING PEE
7
q F,-t NOTICE.TO APPLICAN 1':It,after making this Certificate of Exemption,you shield WATER SYSTFSv TREATING SOILS FEE
a ' become subject m fhe Worker's Cmnpereation provisions of the Lidan Code,you emu
Lkl Iirthwiih comply with such provisionsonhis prrmitshell be deemed reviked. WATER S17RVICE
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CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID Date Receipt X
U. 0 k far
whichthi that there iso issued(Ser.
agency for pcdormance of
the work for which this permit is issued(S<c.7097,Civ.CJ
U. I'" Lender's Name TOTAL:
0 Lendersgddess TOTAL BUILDING FEE
1 ccnify that I have mad this application and sere that the above informant.is
.F. V, correct.I agree to comply with all city and county mdinanres std state laws relining to QTY MECHANICAL PERMIT FEE
V Z building construction.and hereby aahoner representatives ofthis city to enter uponthe SEISMIC HE
atwve-mentioned propeny for inspection purposes. PERMIT ISSUANCE
(We)ogre, armless to save,indemnify uad keep hthe City of Cupertino.gainn ELECTRIC FEE
liabilitienjudgments,costs and expenses which may in any way accrue against said City ALTER OR ADDTO MECH. PLUMBING FEE
in consequence of the granting of this permit.
APPLICANT UNDERSTANCOMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.00 CFM) MECHANICAL FEE
SO=
4,
/9'9 AIR HANDLING UNIT(OVER I10,000 CFM) CONSTRUCTION TAX
S,gmamrc M7qpplicamOCommillnr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant it future building occupant snore or handle haximmus material HENI'ING UNIT TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code Section 25532(.)? HEATING UNIT(OVER 100,000 BTU)
E]Yes ON. VENTILATION PAN(SINGLE RESIU) PAID
Dam RccciplX
Will the applicant or future building occupant use equipment or devices which
nit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(JHP OR 100.1100 BTU) TOTAL: ' d
Disvin? BOILER-COMP(OVER INT"BTU)
❑Yes ON.
AIR CONDITIONER
I have tent)the h ode,Se materials requirements under Chapter rsta of the Cali. ISSUANCE DATE
fmmia g does&tSafetysums Code.Sections 25500.255JJ and 25533.I understand thin if the NEW RESIDENTIAL MECH. SQ.FT.
building does wncarently NaticamaCelity mnotify the occupant
if.ae to the met Friona, reofa Ceniacatysf��.�
igen rr Date TOTAL: ISSUED BY:�
OFFICE
Geotechnical Construction & Design Inc
• 1Y005 Old Vineyard Road JOB Or-98 "Y"VQ SHEET OF
Los Gaws, CA 95030 CALCULATED BY DATES/ 12,9
(408)3544244
Ut,nerml �,npnecrjn&Convector UL�� #A-694188 SCALE NTS FILE # ---IF J —9
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REINFORCING STEEL. CLEAN AND STEEL
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INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
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CITY OF CUPERTINO
• BUILDING PERMIT INVOICE OPERATOR: chrietya
Sec: Twp: Rng: Sub: Blk: Lot:35625003.00
INVOICE DATE......: 09/21/1999
REFERENCE ID # ...: 99090129
SITE ADDRESS .....: 21830 TERRACE DR
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: SINZIG
ADDRESS ..........:
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-4743
CONTRACTOR .......: LIC #
COMPANY .......... :
ADDRESS .......... :
CITY/STATE/ZIP ... .
TELEPHONE ........ :
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- --- --------- ------------ -----------
SPERMFEE P 97.00 0.00 97.00
BPLANCHK A 82.45 0.00 82.45
BSEISMICRE P 0.50 0.00 0.50
--------- ------------ -----------
179.95 0.00 179.95
VtID DESCRIPTION VOICE ID DESCRIPTION
........ ............................ ........ ............................
101 FOUNDATION 102 PIERS
103 LIFER 104 REHAB
105 ANCHOR BOLTS 106 SEWER & WATER
202 UNDERFLOOR PLUMBING 203 UNDERFLOOR MECHANICAL
204 UNDERFLOOR FRAME 205 UNDERFLOOR INSULATION
301 ROUGH PLUMBING 302 TUB & OR SHOWER
303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL
• 305 FRAME 306 HOLDOWNS
307 INSULATION 308 SHEETROCK
309 EXTERIOR LATH 310 INTERIOR LATH
311 SCRATCH COAT 313 ROOF NAIL
501 FINAL ELECTRICAL ENERGY 502 FINAL PLUMBING ENERGY
503 FINAL MECHANICAL ENERGY 504 FINAL BUILDING ENERGY
505 FINAL ELECTRICAL 506 GAS TEST
507 FINAL PLUMBING 508 FINAL MECHANICAL
509 FINAL GRADE 510 FINAL PLANNING
514 FINAL PUBLIC WORKS
•
. CITY OF CUPERTINO
Item 1 of 2 BUILDING PERMIT RECEIPT OPERATOR; christya
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:35625003.00
DATE ISSUED.......: 09/21/1999
RECEIPT 4.........: 10126
REFERENCE ID # ...: 99090129
SITE ADDRESS .....: 21830 TERRACE DR
SUBDIVISION .......
CITY . ............: CUPERTINO
IMPACT AREA .......
OWNER ............: SINZIG
ADDRESS ..........:
CITY/STATE/ZIP ... : CUPERTINO CA, CA 95014-4743
RECEIVED FROM .... : TIM
CONTRACTOR ....... : LIC #
COMPANY ..........:
ADDRESS .......... :
CITY/STATE/ZIP .... ,
TELEPHONE ........ :
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW SAL
-- ---------- ---------- ---------- ---------- ----------
ID -------.DES.... ............. VOICE ID ------ DESCRIPTION
........ . ................
101 FOUNDATION 102 PIERS
103 UFER 104 REBAR
105 ANCHOR BOLTS 106 SEWER & WATER
202 UNDERFLOOR PLUMBING 203 UNDERFLOOR MECHANICAL
204 UNDERFLOOR FRAME 205 UNDERFLOOR INSULATION
301 ROUGH PLUMBING 302 TUB & OR SHOWER
303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL
305 FRAME 306 HOLDOWNS
307 INSULATION 308 SHEETROCK
309 EXTERIOR LATH 310 INTERIOR LATH
311 SCRATCH COAT 313 ROOF NAIL
501 FINAL ELECTRICAL ENERGY 502 FINAL PLUMBING ENERGY
503 FINAL MECHANICAL ENERGY 504 FINAL BUILDING ENERGY
505 FINAL ELECTRICAL 506 GAS TEST
507 FINAL PLUMBING 508 FINAL MECHANICAL
i
CITY OF CUPERTINO
I� 1 of 1 BUILDING PERMIT RECEIPT OPERATOR: chrietya
COPY # 1
Ser. Twp: Rng: Sub: Elk: Lot:35625003.00
DATE ISSUED.......: 09/21/1999
RECEIPT #.........: 10126
REFERENCE ID # ...: 99090129
SITE ADDRESS .....: 21830 TERRACE DR
SUBDIVISION .......
CITY ......... .... : CUPERTINO
IMPACT AREA .......
OWNER ............ : SINZIG
ADDRESS .......... :
CITY/STATE/ZIP ... : CUPERTINO CA, CA 95014-4743
RECEIVED FROM .... : TIM
CONTRACTOR .... ... : LIC #
COMPANY .......... :
ADDRESS .......... :
CITY/STATE/ZIP ... .
TELEPHONE ........ :
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW HAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BPERMFEE VALUATION 4,000.00 97.00 0.00 97.00 0.00
BCHK PERMIT FEE 97.00 82.45 0.00 82.45 0.00
B ICRE VALUATION 3,490.00 - 0.50 0.00 - 0.50 --- -0.00
TOTAL PERMIT 179.95 0.00 179.95 0.00
METHOD OF PAYMENT AMOUNT NUhIDER
----------------- ------------ ------------------
CHECK 179.95 2936
------
TOTAL RECEIPT 179.95