99080042 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY ^
CITY OF CUPERTINO BUILDING-ELECTRICAL 9Q jY PERMITNO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL, 9 I/ .A
BUILDING PROJECT IDENTIFICATION - �f 4
BUILDING ADDRESS, SANITARY NO. APPLICATION SUBMITTAL DATE
OleA) fj4�
A RA TJ,'S NAME' IC yp
All CONTROLM
RCHITECT/ENGNEE LIC NO: j KD S:' El sc ST
ill CONTACT: PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE ❑
1 herehy nRsrm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
W0Z with Section 7000)ofIivision 3 ofthe Businco m o'Isim's Cs r.midmyliecase is RESIDENTIAL:
W O p PERMIT ISSUANCE
C h in full force and eRec D 6 ❑SFDWL ❑KITCHEN REMODEL
eUD Licens a
yr APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
Z i Dam Carl
Convector
< ARC ITECT'S DECLARATION [I MULTI-UNIT El STRUCTURAL
Z p y Z 1 understand my plans shall be used as public records PANELS MODIFICATION
oz—, UPT02MAMPS [1 INTERIOR El CHIMNEY REPAIR
r- Ll F'u1 Licensed Professional 201-I000AMPS IMPROVEMENT ❑SWIMMING POOLS
Y f'� OWNER-BUILDER DECLARATION
94 y1 hereby affim rn that 1 uexempt from the Contractor's License Law formic OVER 1000 AMPS ATH REMODEVREPAIR 0 DEMOLITION
x 3 i Us. following reason.(Section 0031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL OTHER
ad O y which requites a permit to construct.all improve,demolish,or repair any muctum
prior to its issuance,also requires the applicant mrsuch permit to file a signed statement SPECIAL CIRCUIT/MISC.
ythat he is licensed pursuant to the powisin e;of the Contractor's License Law(Chapter 9
Wad C (commencing with Section]IXp)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST COMMERCIAL'
0.q o oC Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION [IDEMOLITION
Section 7031.5 briny applicant for.permit subjects On applicant toe civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
YI nm more man five hundred dollars(5500).
Y IMPROVEMENT
❑ZQ ❑ Lux ework,the property,
sometmmyemployees with wages axmei(Seesole compensation, SWIMMING POOL.ELECTRIC ❑OTHER
22 will domeandthese Concme is ami Livens ur offeredsnot apply
Business
dF d 3 and Professions Code:The Contractor's Choc Iso sacs not apply s if owner of OUTLETS-SWITCHES-FIXTURES
hProlis own who builds or improves thereon,and who nts am n work
te himself or through
his awn owelny he building
that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR SQ
sele.lL however.the building orimpmvemem is sold within one year ofcompletion,ted SQ.FT.FLOOR AREA LSQ.P1'.
mormi-Inolder will have the burden of proving that he did not build of improve for pur-
pose of sale.).
C]1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
constma the project(Sea 7044.Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a contactors)Feel p armaauo the Continental
License Law. PERMIT ISSUANCE
I am exempt under See ,B&P C for this reason
Date EA)
ALTER-DRAIN&VENT-WATER( VALUATION W
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICP.
1 hereby alarm under penalty of perjury one of the following ded:uatons: V
❑o..as and will main mi Section 37 c of me
Code.furt far Wmrkerxce of h- DRAINS-FLOOR,ROOF.AREA,GOND. S RIES TYPECONSTRUCTION
workas provided for mi Section 3]00 of the Wbor Cede,for the pehfnrmonce of the
work far and this permit is issued. FIXTDRE$-PER TRAP Q7�
❑ 1 have and will maintain Worker's Compensation of the
Insurance,as required by Section ✓
3]fXl of me Labor Code.fon performance of the work for which this n d. GAS-EA.SYSTEM-1INC.4OUTLETS OCC.GROUP APN
My W. at o J urepc mer an,
Folic ry� f �p'(j�/'�{J�
Carrier: `h R^� Policy Na.YLY_\ GAS-EA.SYSTEM-OVF.R4(EA7
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREAS VINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
('Thlsseethmaeed mol becampluteddhe pemit is formal hundred doll.($10d GREASETRAP
or Ina.) I PLANCHECK FEE
I certify that in the ifionowe ofthcwork for which finial is issued.I shall SEWER-SANITARY-STORM F.A.200 FT.
oat employ any person in any mutual so as to become subject to the Workers'Compca-
O Z cation Laws of California.Date WATER HEATER WNENT/F.LECTR GRADING FEE
0 Applicant
y NOTICE TO APPLICANT If,after making this Certificate of Exemption,you should WATER SYSTEM/IREATING E
a7 became subject to the Worker's Compensation provisions of the labor Cade,you mull
W forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
�Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID at R
I hereby affirm that theme.consuuctinn lending urgency for the performance of
V 0 the work for which this permit is issued(Sec.3097,Civ.C) 51
R" V Lenders Name L:
Leal Add.. TOTAL:
WBUILDING FEE
1 mod,tiro 1 have read this mpplication and date that the above information is
ZII correct.I agree to comply with all city and county ordinances and state laws reining to QTY, MECHANICAL PERMIT FEE
(,) Z building construction,and hereby authoda repmsentatives ofthis city m enter upon the SEISMIC FEE
Arave-mentioned popery for inspection Imal ea' PERMIT ISSUANCE ELECTRIC FEE
(We)agree to save,indemnify u ilk eep hamhless the City of Cupertino against
liabilities,judgments,coesandex which may in anywayaccomi,dialmid City ALTER OR ADD TO MECH.
in consequence of the�aihnnit. PLUMBING FEE
CANT UN WILT.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000CFM) MECHANICALFEE
O C EGI A
AIR HANDLING UNIT(OVER 10,(X10 CFM) CONSTRUCTION TAX
ignaureol Ap ice Co nor me EXHAUST HOOD(W/DUC) HOUSING MITIGATION FEE
HA RDOUS MATERIALS(DISCLOSURE
Will theepplirma.,future building arapaah stereo-handle hnaafdous mutenal HEATING UNIT(TO I(Ii BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Call Section 255320)? HEATING UNIT(OVER 100,t1W BTU)
❑Yes 0N VENTILATION FAN(SINGLE RESID) PAID
Dam R uipt
Will the applicant or future building occupant use equipment or devices which BOILER-COMPT3HP OR IW,g10 BTU)
mit heaNuus air contaminants as defined by the Bay Area Air Quality Management T L:
District? BOILER-COMP(OVER 100,000 BTU)
ED Yes F1 No
I have read tut he as heti menu under Eloper 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
ryuire
toms el&Suf tion 55 25533 and 25534.1 undersand mm if the NEW RESIDENTIAL MECH. SQ.FT.
nesaol rte it is my."risibility m notify the occupant
m e cote h^atrx3�c
aiwifilartiridifts."AlAre., / Dam TOTAL ISSUED BY:
OFFICE
I
(� CITY OF CUPERTINO
Item 1 of 1 BUILDING PERMIT RECEIPT OPERATOR: nancyc
COPY N 1
Sec: Twp: Rng: Sub: Blk: Lot:36937004.00
DATE ISSUED.......: 09/07/1999
RECEIPT q.........: 9989
REFERENCE ID k ...: 99090042
SITE ADDRESS .....: 20333 CLIFDEN WY
SUBDIVISION ...... .
CITY . . . ..........: CUPERTINO
IMPACT AREA ..... . .
OWNER ............ : THROM WILLIAM W AND MARILYN A
ADDRESS ......... . :
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-4460
RECEIVED FROM ....: DAVE
CONTRACTOR .......: LIC #
COMPANY ..........:
ADDRESS .......... :
CITY/STATE/ZIP ... . ,
TELEPHONE ... .... . :
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
__________ _____________ __________ __________ __________ __________ __________
BP IXTURE UNITS 2.00 16.66 0.00 16.66 0.00
FEE VALUATION 15,000.00 207.00 0.00 207.00 0.00
ECEPT NO. OUTLETS 1.00 1.11 0.00 1.11 0.00
PPERMITFEE FLAT RATE 1.00 35.52 0.00 35.52 0.00
EPERMITFEE FLAT RATE 1.00 35.52 0.00 35.52 0.00
---------- ---------- ---------- ----------
TOTAL PERMIT 295.81 0.00 295.81 0.00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
CHECK 295.81 1250
TOTAL RECEIPT m `295 el
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