00010159 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLYO/`�
CITY UP (a1PERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S
BUILDING,PROJECT IDENTIFICATION
BUILDING DRES' SANITARY NO. APPLICATION SUBMITTAL DATE
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CONTROL»O _� OOH C � INEER; LICNO: ADDRESS.
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BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ . ❑ i7 ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby off that 1 am lieenacd ander provlsi.ns of Chvpmr 9(eommcncing JOB DESCRIPTION
��ZO with Section 700p)of Divismn3 the Business and Professions Code,end ylianse is
HW non,force vnd erten PERMIT ISSUANCE RESIDENTIAL
<UU LicenseC�ass '�r Lic.N - DSFDWL D KITCHEN REMODEL
HGL Do,, Conlracmr APPLIANCES-RESIDENTIAL E3 ADDITION El PLUMBING RE-PIPE
PANELS El MULTI-UNIT ❑STRUCTURAL
OZ t;Z I untlerstand my plans shall be used vs public reroNs MODIFICATION
ce Q
uP T02(10 AMPS El INTERIOR ❑CHIMNEY REPAIR
Lmensed Pmfess�.nal 201-1000AMPS IMPROVEMENT
Syk OWNER-BUILDER DECLARATION Cianc ON DDEMOLSWIMMING POOLS
W 6 1 hereby.(fficoSt"than I am exempt from the Contractors License Law for tM1e OVER It1W AMPS ❑BATH REMODEL/REPAIR ❑DEMOLITION
tS U following mason.(Section 00315,Business and Pmfesxions Cade:Any shy accuracy ❑OTHER
W 3 W F SIGNS ELECTRICAL
=.W.O Na which requires n permit also r1.e wnswn,alter,improve,demolish,or repair any stmcmre
m.] that heor slcense Pubstare 10 theres the applicant
asof for such Compactor'tofile aicense Law
(Chtemem SPECIAL CIRCUIT/MISC.
qty that he isliccnscdpursuantmtheprovisloneofthe Comracnn'sLlcenseLew(Chnptu9
C 6f (wmmencing whh Section 7001 Di vision Sof the Busim,cimd Professions Claude, COMMERCIAL,
W A O TEMP.METER OR POLE INST.
4 k p�G Nm he is exempt therefrom and the basis for the alleged exemption.Any violation of D NEW BLDG/ADDITION El DEMOLITION
Way Section Id'1.5by any applicant for a permit subjects the applicant to n civil penalty of POWER DEVICES
net more than five hundred dollars($500). D TENANT D FOOD SERVICE
CSQ Dl,as owner.fthe progeny,or my employees with weges as'net, -Is compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
CCCi will do the work,and the structure is not intended oroffered forsale(Sec.7044,Business HER
W3 and Processions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
0. French,wbo builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW R14SIDEWIAL ELECTR SQ FT.
sale.If,however,the building.,improvement is sold wimmune,con.fcompletion,the SQ.FT FLUOR AREA $/SQ.FT
ne.f s.1e.) will have the burden of proving that he did not build m improve for Aur-
❑ 1,as owner or the property,am exclusively emanating with bmrr,d conracmm m TOTAL:
construct the project(Sec 70LL Business and Professions Coda)The Corrosions Li-
come Law does not apply to an owner of property who builds or improvesthereon,and QTY PLUMBING PERMIT FEE
who contracts for such prejects with a c meractor(s)licensed pursuant to the Comm ctors
License Law. PERMIT ISSUANCE
D I am exempt under Sec. ,B&P C fonhi,reason
Date ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 700,hereby aflirm ruder pecalty of perjury one of the following declarations Col.`J
❑I have and will maintain a Cenificmeof ConsenFtoself-inmre for Worker's Counted DRAINS-FLOOR,ROOF,AREA,GOND.
tion,as provided for by Section 37M of the Labor Code,for the performance afire STORIES TYPE CONSTRUCTION
Pr which this permit is issued. FIXTURES-PER rRAP
have and will maintain Worker's Compensation Insurance,as required by Section
3700 ofthe L.For Cade,for the perfmmanceofthe work for whicht is permit is named. GAS-EA.SYSTEM-I INC.4OUTLETS4ENERGYFEE
OCC.GROUP APN
My Work 's -sof nsuraeJe cmriePol cych ar�T- GAS-FA.SYSTEM-OVER 4(EA)
CERTI CATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEJINDUSTRL WASTE INTERCEPTOR
This section need not becompleted itch,permit is[Drone hundred dollars($100) =BUILDING DIVISION FEES
or),a.J GREASE'IEAP NCHECK FEE
hat
Loy any fawn in performaanymannce rof the astworkforme subject
ich jethio Permit isirs Compn- SEWER-SANITARY-STORM EA.2W FT.
not employ any person in any manner so as m become subject m the Workers'Compen-
zAppliion Lawx or Cnlif.mia.pateWATER HEATER WNENT/ELECTR
ApplicamNOTICE TO APPLICANT:If,after making Nis Certificate of Exemption,you should WATER SYSTEMITREATING DING FEE
af•" become subject to the Workers Compensation provisions of the Labor Code,you must SOILS FEE
.r forthwith comply with such provisions or this permit shall be deemed revoked.
W� Q WATER SERVICE
'az CONSTRUCT ION LENDING AGENCY NEW RESIDENTIAL FUND, SQ.bT. PAID
I hereby affirm that there is a construction lending agency for the performance of Date ReceiptN
U
P the work for which this permit is issued(Sec 3097,Co.Cr
Lender's Name
U TOTAL:
� Lender's Address TOTAL:
�Y' CL 1 certify that I have road this application and state that the above information is BUILDING FEE
." h correct 1 agree m comply with all city and county ordinances and state laws miming to QTY MECHANICAL PERMIT FEE
U building construction,and hereby authonze repreaemativesofthis city m enterup.n the SE]SMIC FEE
above-mentioned property for inspection purposes.
PERMIT ISSUANCE
(WC)agree m save,indemnify and keep halm an the City iv Cupenst.against ELECTRIC FEE
liablliweccer or the costs and expenses which may many way active against said City
in cnnseyuence or the granting of this permit ALTER OR ADD TO MECH. PLUMBING FEE
APPLICAN NDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(T010,(IW CFM)
SOURCE ULATIONS. l MECHANICAL FEE
4/N es AIR HANDLING UNIT(OVER IRXX CFM) CONSTRUCTION TAX
Signature !Jt
T Cammemr DomEXHAUST HOLD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will theirmllemtorfuture building cecapmt store.,handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Caperton Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(0)4 HEATING UNIT(OVER 100,000 BTU)
"Y" AA No
T� VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupantuse equipment or devices which Date ReceiptN
mit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COST 3HP OR 100,000 BTU)
Disrlot? TOTA
❑Yes �4a BOILER-COMP(OVER 100,000 BTU)
I have read the hazmdous materials requirements under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fornix Health& fety Code,Sections 25505.25533 and 25534.1 umderstmd that if fie NEW RESIDENTIAL MECH. SQ.FT.
buildingdoesn utremly have a tenant,thmit is my responsibility to notify the occupant
77�
of the requi n to which must be met prior m issuance of a Certificate of Occu Z'— L
"i it=oe —��
Owner or au@ t pate TOTAL: ISSUED BY:
OFFICE
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
{• BUILDING PERMIT INVOICE OPERATOR: chriatya
I� �l
Sec: Twp: Rng; Sub: Elk: Lot:37539018.00
INVOICE DATE......: 01/28/2000
REFERENCE ID # ...: 00010159
SITE ADDRESS .....: 869 BROOKGROVE LA
SUBDIVISION .......
CITY CUPERTINO
IMPACT AREA ......:
OWNER SELTZ LEWIS J AND ELIZABETH M
ADDRESS ..........:
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-4633
CONTRACTOR ....... : MCGEE, PAT LIC # 18986
COMPANY WATER HEATERS ONLY
ADDRESS 500 AIRPORT BLV
CITY/STATE/ZIP ...: BURLINGAME, CA 94010
TELEPHONE ........: (415)349-3747
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
1�ID DESCRIPTION VOICE ID DESCRIPTION
...... .......-- . -- .. . -.6 ..............
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 302 TUB & OR SHOWER
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
!.✓qT� l'FEfi1RS ON�b
47-1&79-- 037- /79
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