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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY 000 j o
CITY OF CUPERTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING. MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMIT NO.
BUILDING ADDRESSSANITARY
/a
NO.
APPLICATION SUBMITTAL DATE
—Z ^ Za � cjo
'F.R'S NA E: H
M O
'S AME: LIC N0:
NIC
CONTROL-41!
_
❑
_
R:
INNER: LIC NO
ADI FSS:
ONTAC'1': PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MECH
/
1:1 [:1V ❑
LICENSED CONTRACTORS DECLARATION
I hemhy lbrnt that 1 am hwnsed under provisions of Chapter 9 (rationalism,
QTY ELECTRIC PERMIT - FEE
_ - =.
JOB DESCRIPTION
wrh Section JOp7 ofnivisi0n ofthe Buxincss and Pmfcxi nnsCode, and rylicenseu
in full farce and cRttt. / eY
Limmi.C)ass t� LicM O(
Datefj(��=�e--Contracmr
ARCHITECTS DECLARATION
I undersand my plans shall be used us public records
PERMIT ISSUANCE.
RESIDENTIAL:
[1 STOAT, ❑ KITCHEN REMODEL.
[]ADDITION El PLUMBING RE -PIPE
[:]MULTI UNIT []STRUCTURAL
MODIFICATION
APPLIANCES - RESIDENTIAL
PANELS
UP TO 200 AM I'S
El INTERIOR ❑CHIMNEYREPAIR
IMPROVEMENT []SWIMMING POOLS
Licensed Professional
201-10DOAMPS
m Ce CurthON
1 hereby .(Sect that1 am exempt from the Contns Co License Law for the
Oat I am
following reason. (Section Jo Bu alter and Professions Code: Any city of county
❑ BATH REMODEUREPAIR ❑ DEMOLITION
OTHER
OVER R100AMPS
SIGNS ELECTRICAL
which requires .permit to construct, alar, improve, demolish, or repair any mmcture
str
SPECIAL CIRCUITIMISC.
prior to it, issuance, alwocpaim,dic applicant for such permit to Mexxignedstulemem
that he is licensed purxuant m the ....... ions of the C..ntrucnn''s License Law (Chapter 9
(commencing with Suction 7") of Division 3 of the Business and Professions Code)or
TEMP. METER OR POLE INST.
COMMERCIAL:
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
POWER DEVICES
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
hot more Nan rise hundred dollan(S500).
las owner of the propeny. or my employees with wages as their sole compensation,
d hassle (See 7044, Busine
will do the work, and theswcam is not meendexl..nnivacs
TENANT ❑FOODSERVICE
IMPROVEMENT
❑ OTHER
SWIMMING POOL ELECTRIC
OU'ILF,TS-SWITCHES-FIXTURE.
and Professions Code: The Contrtrors License Law does not apply no an owner of
NEW RESIDENTIAL ELECTS SQ FT.
or improves thereon, pr who nts such work himself oT Through
property employees,
his own however. he provided that such improvements hi unintended h offered for
sale. If, howeveq the building or impmvetttenl is sold within one rear of completioq the
SQ. FT. FLOOR AREA
ASQ. FT.
owner-hadder will have the burden of proving that he did not build or improve for put
-
1. nz auto. of the propeny, .,it exclusively contra...... with licensed cuntncturs to
-
TOTAL.
onstruct the pmjecl (Sec 70H3, Bu,sfncss vad Profemium Crua, lTe Contractor's Li-
-
nse law does murippb'to anowncr of propeny who heldsorimproves theorn. and
Q'TY. F'I.UMBING PERMIT FEE
who contacts for such pmjwcN with a contmcmrfs) licensed pursuant o the Contractor's
PERMIT ISSUANCE
License Law.
Inmcxemptioder. Sec .B&PCIcrthisom,,m
ALTER -DRAIN & VENT- WATEK (EA)
Own Date
WORKER'S ION
COMPENSATION DECLARATION
VALUATION
/�
BACK FLOW PROTECT. DF,VICF.
peca m. cis
1M1anby.(Bete under petperjurywne nfthefnllnwing dorker'i
✓ ((�-//(�J
15 00 0
Co
(have prowled for bynaion37Cement of Consentrsode. sure for Workers Compen-
ion,as pmviJCJ for by Section ?JW of the Labor Crtde, for the performance of the
DRAINS - ILOOR. RODE AREA, GOND.
STORI �
TYPE CONSTRUCTION
o, which thipermil is i :' d.
.y,{h dill 't Workerp :a I ce y'rdby Section
391 of he Luhnr Code ton he ry.doonance nfthe viork fir- wbbb pv mit is issued.
FIXTURES PER TRAP
OCC. GROUP
ARK
GAS FA. SYSTEM -I INCA GUTLOS
My Workcis' m tido'}�y�uy{ d Policy r (�
Cartier C -JI% �>«ti+4 rerrrie Policy No.:�1&
/J
"�}GI S,O�S
GAS - EA. SYS TEM-OVER4(EA)
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASEANDIISTRL WASTE INTERCEPTOR
✓1�k
BUILDING DIVISION FEES -
(Ttisxectionneed not be completed lithe per mit is fnrnne hundred don,es($100)
or less)
GREASETRAP
PLANCHBCK FF.F:
Iat,ml'ythat in the per .... cnceafthe work for which thispunnil isismcd. LOOT
not employ any pc,. in any manners, as to becomesubjectm Ne Workers'Compen-
SL'WER- SAN] 'T'ARY-STORM EA. 200 R.
ENERGY FEE
WATER HGTIiR WNENT/ELECfR
ration laws of Calif scan. Date
Applicant
GRADING FEE
NOTICE TO APPLICANT: IC after maAing this Certificate of Exemption, you should
Lucerne subject in the Wodeds Cuntpcoonskin provisions of the Labor Code, you must
NATER SYSTEMC REATING
SOILS FEE
forthwith comply with such provisions or permh shall be deemed mvoked.
WATER SERVICE
CONSTRUCTION LENDINGAGENCY
I hereby affirm that hem is a construction lending agency for the performance of
NEW RESIDENTIAL PLME SQ, FT
PAID
Date Receipt M
the work for which this peat;, in issued (Sec. 3097, Civ. C.)
Lenders Name
TOTAL:
Lent Adl ::
TOTAL:
BUILDING HE
Ice lythtI have nd [,is applicationd state that the Mt rat is
,.
correct l agree to ouniplb, arliall city and county Ordinancesand rm laws re.afing no
building construction. and hereby authorize representatives of this city In enter upon the
QTY. MECHANICAL PERMIT FEE."
SEISMIC FEE
PERMIT ISSUANCE.
ELECTRIC FEE
above-mentioned propeny for inspection Follows.
IWO agree to save, indemnify and keep harmless the City of C.,mho against
PLUMBING FEE
Iiabildies,judgmems. costs and expenses which may in any way neem, against said City
he granting of this permit
ns&t`
ALTER OR ADD TO MECH.
1{gNDLING UNIT (l'O III,IXNI CPM)MI'AHANIGL
PBE
APPLIBRSTANDS AND WILL COMPLY WITH ALL NON-POINTAIR
TIONS.
AIR HANDLING UNIT (OVER IB,WCFM)
CONSTRUCTION TAX
/yam
Sfgnnarttic -muche or Dam
EXHAUST HOOD(W/DUCG
HOUSING MITIGATION FEE
AZARDOUS MATERIALS DISCLOSURE
HEATING ON[ "T(TO 100,000 BTU)
Will the a,hunnt or hatem building oceupom,nuc or handle havadous malarial
as refined by the Cupertino Moniei.ul Code. Cha v,r9.12, and the Heath and Safety
Code, Section 25532(07
[D Yo, �(�p�
IIEAING UNIT X)
T (OVER 100,011'I Or
PAID Date RuciptN
VENTILATION FAN (SINGLE RPSID)
BOILER -COMP (3HP OR 100,000 BTU)
Will the applicant or future building excellent use equipment or devices which
t hazardous atrcnmart rt as defined b the Bu Arca Air Quality Management
Y Y Y� g
ll
TOTAL: � V
BOILER - COME(OVER 100,001 B'rl))
�saiet7
❑ Ycs
AIR CONDITIONER
I have real the hicaNnus camenalsnomaciesents under Chapter 6.95 of the Cali-
ISSUANCE DATE
NEW RESIDENTIAL. MUCH. SQ. F -P
forma Health alely Code, Stttionz 2 25503 amp that if the
I uMetify
th
nidal
buildingd s ready M1uveamnant. that it is my merymsibiliry to notify the recupam
that i
of the of ns which ma th. met prior to issuance of a Certificates nl'Occ'pan y.
ISSUED BY
TOTAL:
OwnersDam
OFFICE
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
BUILDING PERMIT INVOICE OPERATOR: ChriStya
Sec: Twp: Rng: Sub: Blk: Lot:36651005.00
INVOICE DATE......: 01/28/2000
REFERENCE ID # ...: 00010153
SITE ADDRESS .....: 11530 UPLAND WY
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: BUSCH JOHN R AND WENDY L
ADDRESS ..........:
CITY/STATE/ZIP ...: CUPERTINO CA, 95014-5104
•
CONTRACTOR .......:
GILROY, JOHN
LIC # 15128
COMPANY ..........:
JUST WATER HEATERS INC
ADDRESS ..........:
1764 NATIONAL AVE
CITY/STATE/ZIP ...:
HAYWARD, CA
94545
TELEPHONE ........:
(510)293-9901
FEE DESCRIPTION CHK TOTAL FEE PAID -TO
-DATE BALANCE DUE
----_______
--------------- _-_
BPWHEATER P
------------
9.99
0.00 9.99
PPERMITFEE P
35.52
0.00 35.52
---------
------------
45.51
-----------
0.00 45.51
VOICE ID
DESCRIPTION
VOICE
ID DESCRIPTION
SEWER & WATER
202
UNDERFLOOR PLUMBING
ROUGH PLUMBING
302
TUB & OR SHOWER
502
FINAL PLUMBING ENERGY
506
GAS TEST
507
FINAL PLUMBING
•