00010138APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE SALL POINT PEN ONLY 00010/ 3 9
BUILDING - ELECTRICAL
CITY DI CUI'ERION PLUMBING. MECHANICAL.
HmLD]NCyurvISION APPLICATION /1'ERMI'C /r,:� BInLDING PRw1:C1'.mF.NTIFIGTUm ^•;:rgyrl"
PERMIT NO.
C
�J
DU 11 INGADDRISS:
/oBo2 A /der6141 k /one
SANITARY NO,
APPLICATION SUBMITTAL DATE
NER$�Nq{ M.,G 1'HON': /J
1YlA GYr1U/ V — — t
CON TOR'S AMID L1 NO
/f7 p(J /
N/C
❑
CONTROL#
ARCHITECT' /ENGINEER: LIC NO
ADDRESS:6r ) five, C' —n /ter
�i Y/VO lXI l[A
CONTACT: PHONE:
❑
Consultant Fees Paid by Applicant (Initial)
'f'rl!4r',f if 6UILDING,PERMIT INFO,!' :-
BLDG ELECT PLUMB MECH
❑ ❑ d ❑
-
LICENSED CONTRACTOkS UECLARATION
I herch Iran neat 1 .nr licensor under
yn pup enama9m mice sins
Z whM1 Ser;nn ]IX)0panrvisimr none nn,Nexn rarer orenn nn a,de. and yliawxe is
O in (all (arcs and elfat.
I" License lass Lich
4Ul Dwc. •n Cnroolic
IQTY
I ''r(fj ' f
- ELECTRIC PERMIT: !1
I : - - .. r fl 'f If
ter 1(
I'Ee
/ u/
JOB DESCRIPTION
RESIDENTIAL'
❑ShIJWL E3 KITCHEN REMODEL
[]ADDITION ❑ PLUMBIWG RE -PIPE
❑MULTI-UNIT []STRUCTURAL
MODIFICATION
❑IMROVE ❑ CHI MNEYREPAIR
IMPROVEMENT
❑ BATH REMODEUREPAIR DEMOLITION
OTI {ER
PERM]) ISSUANCE
APPLIANCES — RESIDENTIAL
H CHI TECT'S DECLARATION
ZZ 1 under.mnd my proms shall he axed as public records
pgNF.IS
UP TO 20(t AMPS
u] Lirenred Profesfionul
OWNER- yUUDERDECLARAImeo
R I hereby affmi that I nor exempt frmn the CantrroCoa License Law far me
U following reason (Serino 7031.5. Business and Podessinn Code.: Any city nr coumy
ya prior rM1 its issuance, x u permit to requires the applicant nt forsa, demolish, ore asigned i any t temare alle"
J at he its sense WSO mgaims thovi,to ca ItheChpermiuoicens w(Clumem
(commencing cing with pursuant m One of Disinio of the COm sines License Law fC orris) 9
(comic eiag,,O,h.eJnn9IXp) ofDivisi frofatcgrd w.forEProfessions Code) or
e that Section is 70315 b faeref ium and foe basis fns be alleged applicant to Any l Penalty of
tt.a,,(mrethanve hundred dollars subjects the epplicummvcivil penalty of
any � not more then live M1UVdrcd dollars ($SqB.
C] Las owner of the pn)peny. or my employees with wages as their sole compenation,
e will do the work, and thannicure is not intended nr uffered for sure (See 7(W. Business
so and Professions Code: The Confracmr's I.icense Law Lines not apply to an owner of
progeny who builds or improves thereon and who does such work himself or through
his own employees, provided that such improvements are not intended oz orfared or
sale. If, however, the building or improvement is sold within cneycm mfcompletinn ,fhe
caner,mulder will have (lie burden of proving that he :lid not build or hnpove for pvr-
,,e of m1eJ.
❑ I, as owner of (he popany, am csdnsively mmmcdng with Ikcnsed contractor to
cony OM1 project (Se 70X48 and P fe. :Code:) M C t t La
woncause Law does f apply loan fpr p ny n b'ld p : th d
mrdcrx for.xnchp ices with a comr mr(s)Icened pursuant to the Commcmrx
License Law.
I am warp, under Sea. ,B& P C forth]; rwxan
201- IwOAMPS
OVER I" AMPS
SIGNS ELECTRICAL
SPECIALCIRCUIT/MISC.
TEMP. ME? Ell POLE INST.
COMMERCIAL'
❑NEW SLUG /ADDITION ❑ DIiMOLIMON
El TENANT Cl FOOD SERVICE
IMPROVEMENT
❑OTI IER
POWIiR DEVICES
SWIMMING POOL ELECTRIC
OUTLETS — SWITCHES — FIXTURE
NF.W kE51DENTIAL ELECTR SQ
SQ. FI'. FLOOR AREA
$ /SQ: F,
Lo
QTY.
lI 'r ,rs-
�(k.:f t'(� PLl1MBINC PERMIT, k. (frlr'
'r rr,'•
6',•t. •fF_`I
PERMIT ISSUANCE
ALTER — DRAIN &VENT — WATER (EA)
f
'ne r Doc
VALUATION
L�'/'1I'l M
J 00 CO
WORKERS COMP12NSNYEON DECLARATION
I hereby offrm under penalty of perjury one of the following deelamfion:
❑ I have and will not sCenircamof Cnncnt w rialf- insure for Worker's Cooper-
xafirn, ax pmvidvd hn by Section 3700 of ❑m Labor Code. for fhe peifurranm of the
for which Nis permit is issued
r rOa and will nwinfain Workers Cnmpunsafion InN mace, a, rapt and by Suction
DWn(the LnMr COdey,Wfor the perfarnanee mf the worA fnrwhichfhis perm's issued.
so, Ca er:t rtt'1= [J[J[./ lIONYNn.y �
Cl I'ICAI E OI: EXIiMPI'ION FROM WORKERS'
COMPENSATION INSURANCE
('I his section need not he mmplctrd if marputmif is manne hundred dollars
or less.)
1 cenify that in the perl'nnnanceof the work far which this psmal is isuad, l shall
nor employ any person in any manner sr avo became object ionic Workers'ComNm-
' smimn lawn of Calimmia. Dane
Applicant
BACK PLOW PROTECT. DEVICE
DRAINS — FLOOR, HOOP, AREA. COND.
STORIES
TYPE. CONS'IRUCfION
FIXTURES — PER 'rRAP
GAS— EA.SYSTEM.I INC.40UTLETS
OCC. GROUP
APN
9.— O n3
(/ (y
GAS —EA. SYSTEM oVEk4(EA)
GREASMAIDUSTRI. WASTE INTERCEPTOR
- BUILDING DIVISION FE0.5
GREASE TRAP
PLANCHECK FEE
SEWER— SANI'T'ARY —STORM EA. 200 FC
ENERGY FEE
WgTFR HEATER WNF.N'1'/ELIiCTR
GRADING FEE
iNOTICE TO APPLICANT If, afmr, making this Carnicae of Exemption, you hn.5
become at,hj,c, an he Workers Compsnnfinn provisions or the Labor Coca. you must
fonhwuh Comply with such provision, or Nix permit shall be deemed revoked.
a
CONSTRUCTION LENDING AGENCY
Ihwebyuairmthe Neick.con'wafimi lending agency for 'he parrnmunce of
the work for which his permit is issued (Sec. 3099, Co, C.)
Lauder'; Name
Lenders Address
1 cenify Nat 1 have read this ppl' a f and state tat the bo ve informanter
nrreef I ogres ¢r comply 1M1Ol city do ry d' and .mmP refining t
building can,Wrion and hereby authorize reprearatves of this city to enter upon the
rhos, mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
luhllion,judgmunts,costs:mJ expcnxcs which may In any wiry namengaind said Ciry
in consequence of the granting of this permit.
APPLICANT tRSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE kE( -L IONS.
O
WATER SYSTEMaRBAI'INO
SOILS FEE
WATER SERVICE
PAID
NEW RESIDENTIAL PLMIL SQ. Fr.
Dam Reeeipi#
TOTAL
TOTAL:
BUILDING FEE
-
QTY.
-
1' lif4 MECHANICAL'PERMIT 1' f 11
't( kls:r• •. /l tr „ /k /.
{{
' 1 "'E �x /
f. r/+ s l.8
SEISMICFEE
PERMIT ISSUANCE
ELECTRIC FEE
ALTERORADUTOMECH.
PLUMBING FEE
AIR HANDLING UNIT (TO HIOM CFM)
MI!CI IANICAL FEE
AIR HANDLING UNI'F(OVER 10,000CPM)
CONSTRUCMON'I'AN
9ignulure al Appl' nor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Occupant sore or handle hazardous material
as definrl by Nc Cupertino Municipal Code, Chaps, 9.12, nod the Health and Safety
We. Section 25532(x)]
❑Ya
1 emit hazardous air contaminants as ddined by the Bay Area Air Quality Management
Wrdusair onto or building ired by the Area Air moot Mmuraement
Uisaim9
❑Yes �o
I M1a ¢read fhe hamNOn mamrialert requirements under Chapter 6.95 of the Cali
quirtmen p
bfnmia Her & Safety Code, Safionn 2550.1.2.9.933 is my and 255]4.1 Or notify undersold Nc If Ne
uilding it currently have be me, pro,, ismycrof.CcciyernrnifDec occupant
o[ fh a which must be met prior m issunncv of a CeniOwmuf Occupnncy.
EXHAUST HOOD (W /DUCT)
HOUSING MITIGATION PEB
I IEAI'ING UNIT TO I00.(X)0 B'I'U)
HEATING UNIT (OVER I nIdIXO BI U)
PAID
VBN'TILA' ON VAN (SINGLE RES O7
Data Racips #
OILER— COMP IP 011100,IH)0111 U)
TOTAL:
�a J
BOILER — COMP(OVER 100,01)11 B'PU)
AIR CONDITIONER
ISSUANCE DATE
-
-
ISSUED BY: &— m cc''
NEW RESIDENTIAL MECH. SQ.
Owner ores gem ate
TOTAL:
OFFICE
880 Dubuque Avenue
NetClerk, Inc.: e- solutions for the contracting industry South San Francisco, CA 94080
(888) 88 CLERK
f
Building Permit Application
From: NetClerk Inc.
Contact Name: Scott Waterbury
Phone:
Fax Number:
(650)624 -0426
1- (877)846 -5888
To: Building & Planning Department
City: Cupertino
Phone: (408) 777 -3228
Fax Number: (408) 777 -3333'
Permit Handling Instructions
Please Fax Permit to: 1- (877)846 -5888
Deliver to job site at first inspection
I will pick permit up at the Building Department in 5 days LJ Please mail original to Contractor address below
Other:
Contractor Information
Company: Hot Water Inc.
Contractor:
Address: 2531 Graceland
City: San Carlos, Ca. 94070
Phone: 650- 298 -8494
•lax: 650- 298 -8493
Email:
Comments:
Fax
Authorization forms:
2. "Agent Authorization„- By completing and returning the information below,
you authorize Net Clerk, Inc. to act as an agent on you behalf
To Whom it May Concern:
Let this letter authorize NetClerk Inc. and all currently employed and
authorized associates of NetClerk Inc. to act as an agent on our behalJ'-
signing for any and all building permits and licenses required by our
company.
Sincerely, 1k
Name: A,; s 6t, v la,
-Title: 111,13
Comapany: A4 M/c-/U . Y1 n c-
Worker's Comp #: 1548386 State Fund
State Contractor's License # 763612 C36
Credit Card Information
Credit Card Number: 4246- 3115- 0117 -2578
Name on Card:
Expiration Date:
Visa n
Chris P. Guslani
06/00
MasterCard
Credit Card Authorization
Company Name:
Company Address:
O
Phone: bSL- D9g -8�4~
Fax: / b..79g- J
Email: r..] �,Ce
Type of Card: --Visa MutelCard
TCardholders Name: �3✓69iiS Or/ 5 8
>Iccmdit Card n: Expiration Date: G as
By signing below, I give NetClerk, Inc. and all currently employed and authorized
associates of NetClerk to sign credit card authorizations for the purpose of permit
applications.
Cps ;s 6"S)dnf �/AL r. AL n 1s y
Contractors Name Signature Data
INVOICE" INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
• CITY OF CUPERTINO
BUILDING PERMIT INVOICE OPERATOR: christya
Sec: Twp: Rng: Sub: 131k: Lot:36920030.00
INVOICE DATE......: 01/28/2000
REFERENCE ID # ...: 00010138
SITE ADDRESS .....: 10828 ALDERBROOK LA
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: KRISNAMURPHY, V.
ADDRESS ..........:
CITY /STATE /ZIP ...: CUPERTINO CA, CA 95014 -4606
CONTRACTOR .......:
GUSLANI, CHRIS
LIC W 21311
COMPANY ..........:
HOT WATER INC
ADDRESS ..........:
2531 GRACELAND AVE
CITY /STATE /ZIP ...:
SAN CARLOS, CA
94070
TELEPHONE ........:
(650)298 -8494
FEE DESCRIPTION CHK TOTAL FEE PAID -TO -DATE BALANCE DUE
--- ----- - ------ ___ _________
EPWHEATER P
____________
9.99 0.00
-----------
9.99
PPERMITFEE P
35.52 0.00
35.52
______
___ __ __ __ ______
45.51 0.00
__ ___ _ ___ __
45.51
A ID DESCRIPTION
VOICE ID
DESCRIPTION
........ ............................
106 SEWER & WATER
........
202
----------- . -------
UNDERFLOOR PLUhIDING
301 ROUGH PLUMBING
302
TUB & OR SHOWER
502 FINAL PLUMBING ENERGY
506
GAS TEST
507 FINAL PLUMBING