29094 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES=USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL PERMIT NO. 2.9 0 w 4
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. L {JJ
BUILDING PROJECT IDENTIFICATION
BUILDING DURESS: SANITARY NO. APPLICATION SUBMITTAL BATF
O E N PHONE CONTRACTOR'. NAME: LIC
0 C SAC CONTROL#
RCH CHENGINE R: LIC NO: DDREES : / ❑
CONTACT: P E: 1 BUILDING PERMIT INFO
G /_ �/a .❑ Consultant Fees Paid by Applicant(Initial) B� E� PLUM MECH
(� #ate 9 `f90
LICENS D CONTRACTOR'S DECLARATII QTY ELECTRIC PERMIT FEE `f'
I hereby union that I am licensed under Provisions of Chapter 9(commencing JOB DESCRIPTION
'01 0z with Srxtum70M.fDivisi n3 tax Businessand of . nslandm licemais
00 - PERMIT ISSUANCE
t-, in full force and ofcet. FDW L ❑KITCHEN REMODEL
<U License Cleats Lick APPLIANCES-RESIDENTIAL ❑ DMON ❑PLUMBING RE-PIPE
Date Conwetor_(" j _
Z 0 R ETEGTS DECLARATILfbT"a• ❑MULTI-DMT ❑STRUCTURAL
PANE S
vv�2 I understand my plans shall be used az public rccrrds MODIFICATION
iOZ%JO UPT0200AMPS [I INTERIOR ❑CHIMNEY REPAIR
I-!r/„J a Licensed Professional 2(11-I000AMPS IMPROVEMENT
P9G 'I OWNER.BUILDER DECLARATION
y t I hereby affirm that 1 ran exempt from the Commcwr's License Low for the OVER I1100AMPS [I BATH REMODEUREPAIR ❑DEMOLITION
56060 following reason.'(Section]031.5,Business and Professions Cale:Any city or county SIGNS ELECTRICAL []OTHER
LL7 000 poochrequires apermit reennei the applicant
Perlia ore a sig anymm�ure
arm an heislcenseo,alsa mgoires previsions ofthe sucCommacmiuoicense aw(ned ummem 'SPECIAL CIRCUTT/MISO - _
;F Nei M1uchri gwit pSectiou the 0(ololvixions I Ne Conwcmrsial Prmlaw(Cholelr9 _
QF twmmes exempt
]andth basisan3 of Neeged essanJon.An iunsCdc)or TEMP.METER OR POLE INST. EOMMPprIp L:
L�"0 0a that he is exempt therefrom and the basis far the alleged exemption.Any violation of El NEW BLDGIADDITION�A AOLITION
N Section 7031.5 by any applicant fora permit subjects the applicant ton civil penalty of POWER DEVICES ❑TENANT ElFOOD SERVICE.
} notmmeNanfivehdred
undallars(4500). IMPROVEMFEB 21
❑ has owner of the propmy,or my employees with wages us their sole compensation, SWIMMING POOL ELECTRIC 'If1(]�
0 will do the work.and the swcutn is not amended oroffamd forsole(Sec.1044,Business ❑OTHER ILa�774i
and Professiam Coda The Cmnactors License Law Jae not apply to au owner of OUTLETS-SWITCHES-FI%TURES rIT6
pnryerty who builds or improves thereon,and who does such work himsell'or through - ''CYT bt l#( r CH
his own employees,provided apt such improvements ore not intended or offered for NEW RESIDENTIAL ELECTR SQ%W. '-
sale.If,however,the building or improvement is sold within one year ofcomplerion,Ne SQ.FT.FLOOR AREA s/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur. 4q 11 ��n
Few is owner
®� ek'.l.N/.\LL,7
❑hon owner of ct property,nm exclusively Professions
with:)The
ameaetms m
conseua the project apply
](N4.Business and property
who
Cale:i The Camacton,Li
cat
ense Lowdtses'nmupplywon with
ofpropcny who sed Fireman to the Canon.and QTY. PLUMBING PERMIT FEE
who contracts for such pmjeea with n contaeior(s)licensed pursuanuo the Conwcmis ,
License Law. PERMIT ISSUANCE
❑I am exempt under Sec. ,B&P C for this reason,
Owner Orae ALTER DRAIN&VENT-WATER(12A) - VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
E hereby affirm under penalty of perjury one of the following declarations: L b
E] DRAINS undwill maintuina Cenifivmwd Consennosdf-insum Ra Workels Compcn- DRAINS-FLOOR,ROORAREA,CO STORIES TYPECONSTRUCTION
sedan,as provided far by Section 3700 of the Labor Cade,for Ne perforromen of the ,
wad for which this permit is issued. FIXTURES-PER TRAP '
❑1 have and will maintain Workers Compensation Insurance,as required by Section
3100 of the Labor Cal,for performance of the work for which this permit is issued. GAS-EA.SYSTEM.I INCA OUT OCC.GROUP APN
My Worker Camp s ri I Te n l$ytance carrier and Polic em r air.
Certier. _Policy No GAS-EA.SYSTEM-OVER 4(EA)
CE&AMWeOF EXEMPTION FR W SRI ERS' GREASEINUUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
Ghk ed section nenot be completed if the permit is for one hundred dollars Is list)i or less.) GREASETRAP PLANCHLCK FEE Wxb.O
Icenify Not in the performance of the work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 PT.
nor employ any person in any manner so as m hcama subject w the Workers'Compen- ENERGY FEE
Z nation Laws of Califomia.Date WATER HEATER WNENTIELECA
7� Applicant - GRADING FEE Lail A
r
a NOTICE TO APPLICANT.If,Mer raking this Certificate of Cxempmet,you should WATER SYSTEM/TREA'UNG SOILS FEC
I" become subject tat the Worker's Compensation provisions of the Labor Code,you must
Wforthwith comply with such pmeiamns or this permit shall be deemed revoked WATER SERVICE
Q
CONSTRUCTION,isacoLENDINGACCNCY NEW RF.SIDF,NTIAI.PLMB, SQ.FT. PAID
V0 l for whihthis ethere isued(Sec.3 loading agency for the perfowuna of a Rciptp
T+ Laders for which this permit is issued(Sea 309],Civ.CJ
0 F' Isndele Name TOTAL:
V Leaders Address
f 0I certify met I have read Nis upplicmilm and sate that Ne above information is - BUILDI 'FEE�r^ ta/1 co rrect.I agree to comply with all city and county ordinances and sure lows relating to QTY MECHANICAL PERMIT FEE
V building construction,and hereby...term represumbuiva of this city to emerupon Ne SEISMI
above-mentioned property for inspection purposes. PERMIT ISSUANCE ♦� peF,�
(We)agree to save,indemnify and keep Intermixes the City of Cupenino acmuot ELECTFEE
liabilities,judgments,costs and expenses which may in any way name against said City ALTER OR ADD TO MECHm
in emsequcnce f,he gaming of this permit. P1.0f%<
A PLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,01x)CFM)
MEC ICA TEE
GUWTIO S. 1
(�/y�/ AIR HANDLING UNIT(OVER 10000 CFM) CONSTRU TAX
A piton cmr LLL Uvte EXHAUST HOOD PNMUCT) HOUSING MTUGA NFEE
HAZARDOUS MATERIALS DISCLOSURE
Will to,applicant or future building occupant store or handle haaaMnus material HEATING UNIT(TO IM.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532nd? HEATING UNIT(OVER 100.00E BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
WIII the epda,am or future building eventual use equipment air devices which Dvte - Receipt#
•i emir hazardous air conuminunrsaz defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR I00,(x10RTU) TOTAL
Dierict? BOILER-COMP(OVER 100,1100 BTU)
❑Yes E]No
I have read the haaardous materials requirements under Chapter 6.95 of the Cali. AIR CONDITIONER ,ISSUANCE DATE
famin Health&Safety Cade,Sections 25505,25533 and 25534.1 muc ersuand that if Ne NEW RESIDENTIAL MECH. SQ,FT.
Wilding does rid nurtndy have#transit,that it is my responsibility m notify the axapanr
of the requirements which most be mer prior to issuance of a Cernfecare of Occupancy '
Owns or oulmined agent - Date ISSUED BY:
OFFICE
R J HICKENBOTTOM CIVIL ENGINEER
120 JUSTO CT
CAMPBELL, CA 95008-5312
(408) 379-9252
Sep 20, 1999
AQUATIC TECHNOLOGY POOL AND SPA
P 0 BOX 26445
SAN JOSE, CA 95159-8455
831-636-6804
SUBJECT: Survey back yard for pool forms location
A new pool for Mr. and Mrs Doran Drusinsky
11425 Charsan Lane, Cupertino Ca 94014
�9o8o�r g
GENTLEPERSONS
The pool forms locations setbacks have been surveyed in the
field and findings are as follows :
1) The forms are clear of the 10 ft Sanitary Sewer Easement
along the Railroad (East) property line.
�=- - —
--2) The water-' s--edge .will be 5+-.f.t_ clear- .of the-back (North)
property line .
3) The City Code requires 5 ft setback from property lines
to water edge . The pool forms are found to be at 3 . 1 ft, which
would be 4 . 1 ft from property line to waters edge. The west
forms will therefor need to be relocated in order to conform.
Enclosed is a plat at 10 scale showing property lines,
pool forms, trees, existing house building line and SSE. Please
let me know what you decide.
If you have questions please call me at (408) -379-9252 .
Respectfully
Richard Hickenbottom
r* ?Pb6w Sa 1 v'9-c -}U ,>esAeJ