00010031APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY 00 0) 0 0 -2;3 I Otola q
CITY OF CUPERTINO BUILDING -ELECTRICAL PERMITNO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAI, SOOOI
BUILDING PROD CT IDI:NI'1 FICATION
BUILDING ADDRESS: / � SANITARY NO. APPLICATION SUBMI'ITAI. DA TE
/0 "72-0 i 1A1A,&7/Sn/1% aR _ I �/O 00
Welaf "A
Ig:co]Ng
❑ Consultant Fees Paid by Applicant (Initial)
1 hereby affirm that I on licensed andel provisions of Chapter 9 (commencing
wiseSeedual'ag)IofDivision3of the Business and PmfexsitnsCode. and my license is
in full force and effe
GU V License Class Lw p / �O
YI Dun Conor cinr
ARCHITECTS DECLARATION
y3 I understand my plans shall be used m public records
Z --
,,FM Licensed Pfofessiunal
OWNER -BUILDER DECLARATION
I hereby nllirre than I um exempt frons the Contractor's License Law for me
"LL U following reason, (Section 1031.5, Business and Professions CWc: Any city or county
OLL which armors a permit to construct, alien improve, demolish. or repair any .'me
prim u, as issuance, also requires ser applicant for welt pcmar m file a signed xlmemrm
ytbut he is licensed pursuunl to 'he provisiotunf the Canrmnm's License Law (Chapter 9
as(ith See.. of Division 3of the Basin,"and Pmfessions Cede) or
bcommencing w
`ym pf that he is exempt therefrom and the basis for the alleged exemption. Any violation of
al k. Section 7031.5 byany applicant for o permit subjects the applicator a civil penalty of
I. X z>. or more than five hundred dollars(S5D9).
st
❑ 1, no owner oldie properly, m my employees with wages as their sole compensation,
Pq� will do the work, and the structure is not intended or offered
e:Thfuroate (Sec. 7044. Business
d 5 and Professions Car'e Convenor's n's License Law does not apply m an owact of
property who 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
sale. If, however, the building or improvement is sold within one year of completion, the
nenhuilder, will have the burden of proving What he did not build or improve for par
pose of sale J.
❑ 1, as owner of the property, am exclusively convening with licensed contractors to
consumer the project (See. 4044, Business and Professions Code:) The Contractors Lk
ease law door ma apply to as owner of property who builds m improves thereon, it QTY.
who contracts for such projects with a contmemr(s) licensed pursuant o the Contractor's
License Law.
❑ 1 um exempt under Sec. . B & P C for this .,,an
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UPTO 2M AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL FLEM SQ FT.
venni [)are WORKER 'S COMPENSATION DECLARATION
I herehy infirm ander pewhy of perjury one oflhe following declurnro w
1 have and will maintain aCel ificale of Conscm to self -insure for Worker's Compen-
sation, as provided for by Section 37W of the Labor Code, for the per'mrnance of the
work for which this permit is issued.
1 have and will maintain Workers Compensation Insurance, as required by Section
370hdme Labor Code, for the Leffourn4o of the work fm whi�chjfnhis Pkaral is issued.
My arker�yrljp Ar im rvnc ievolcy Noy.Carme•���`3�
/CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Unissexamn need mol he comple d if the Permit is faon< hundred dollars ($1110)
or less)
I cenify that in the performance of the work for which this permit is issued, I shall
non employ any person in any manner so us to become subject the Workea' Comprn-
n sedan Laws mCalifornia. Dole
zO Applicant
ti NOTICE TO APPLICANT. If, after making this Cenihcate of Exemption, you should
(•-' become subject an she Workers Compensmim, pawkilms of the Labor Cale, you most
for uxith eanply with such provisions or .his permit shall br deemed revoked.
CONSTRUCTION LENDING AGENCY
U p l for whilhmethermil i issued(See. 30ur lendinagency for the performance of
F
Lenders Name for which this permit is Issued (Sec. 309], Co.. CJ
OU Learns Nam<
{2i LenJcrI Address
G 1 cenify that 1 have toad this y and out and smm that the slow l iws relating is
r) Z correct.) anter to comply with all city end county ordinances and state laws relating to QTY,
U Z may,n-mems and proend hereby amhorixrtp,icti. Ives of this cirymenmr upon site
vMrvc-mentioned to ertysave forinspectiona keepha.
(W<)agree to Cove, indemnifyadharmless wCityay
Cupertino datum
Iiahilities,ju0gmenss, Costs and expenses which may in any way accme uguitat said City
in consequence mine granting of this permit.
APPLICANT UNDERS'TANOS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building ooerforl storem handle huaardnus material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532fa)?
❑Yes ON.
Will the applicoa or future building occupont use equipment or devices which
I'll hvordous air contaminants as defined by the Boy Arca Air Quality Management
Di.Grict?
❑Yes ON.
I have read the hazardous mmeials requirements under Chapter 6.95 of the Cali-
fornia Hexlm & Safety Code, Sections 25505, 25533 and 25534. 1 understand that if me
building dm not comently have a ¢tans, d a n is my dopmee ibility m nmify me occupant
of oho requireawats which must he met pdor m issuance of Certificate of Occupancy.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN &VENT- WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS -FLOOR. ROOF, AREA, COND.
FIXTURES -PER TRAP
GAS - EA. SYSTEM-) INC. 4 OUTLETS
GAS - EA. SYSTEM -OVER 4 (EA)
GREASIIINDIISTRL WASTE INTERCEPTOR
GREASETIU P
SEWER - SANITARY - STORM IIA. 201 PI'.
WATER HEATER WNENTIELECTR
WATER SYSTEM/TREATING
WATER SERVICE
NEW RESIDPNTIAL PLMB. SQ. FT.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT(TO 10,011f) CFM)
AIR HANDLING UNIT (OVER 10.00 CIM)
FAHAUST HOOD(W/DUCT)
HEATING UNIT (TO 100.00) BTU)
HEATING UNIT (OVER 100.000 BTU)
VENTILATION FAN (SINGLE. RESID)
BOILER -COMP f3HP OR 100.000 BTU)
BOILER - COMP (OVER 100,000 BTU)
AIR CONDITIONER
NEW RESIDENTIAL. MECH. SQ. F1'.
TOTAL:
OFFICE
FEE
FEE
0
BUILDING PERMIT INFO
ILDG ELECT PLUMB MSCI
❑ ❑ 11 ❑
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL ❑ KITCHEN REMODEL
❑ADOPTION El PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT ElSWIMMING POOLS
❑ BAH OTTEREMODF:1/RE91�R OD yea
FII i0C f
OMMFR IA
❑NEW BLDG/ADDITION ❑DEMOLITION
❑TENANT ❑FOODSERVICE
IMPROVEMENT
❑OTHER
SQ. FT. FLOOR AREA I .LSQ. FT.
%fid 0�
:Toot FS TYPE(
7rS 3y 02
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS HE
PAID
Date Receipt g
BUILDING FEE
FEE SEISMICFEE
ELECTRIC FEE
PLUMBING FEE
MECI IANICAL PEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID--
Dare Receipt#
Ire
JRN.10.2000 10:21PM NETCLERK INC NO.894 P.2
CITY OF CUPERTINO
BUILDING PERMIT APPLICATION
10300 Torre Ave. Cupertino, Ca, 95014
(408) 777-3228
PROJECT ADDRESS: 10720 CULBERTSON OR BLDG # SUITEIAPT #
PROPERTY OWNER CONTRACTOR
OWNERS NAME: ADRIANNE ZIFF
NAME WATER HEATERS ONLY, INC.
MAILING ADDRE66:10720 CULBERTSON OR
MAILING ADDRESS: 970 E. MAIN ST. #200
CITY/8TATE2IP: CUPERTINO CA
99014 CITY/STATFIZIP: GRASS VALLEY CA 85949
PHONE #: ( 408) 25334M PAX #: ( )
PHONE#: ( 1141100833-4572 FAX (k ( 539274.3065
E-MAIL ADDRESS:
B•MAIL a0DRE98: N20NTRONLY®AOL.COM
AI. Dz,;2—
BUSINESS LICENSE#:
EXPLAIN WORK TO BE PERFORMED: WATER HEATER REPLACEMENT '
• BUILDING: ELECTRICAL; MBCPATNICAL: PLUMBING. 6'
RBROOF: HAZARDOUS P1RE ARBA: YES: NO— NUMBER OF IDOSTING ROOF COVERINGS: 0
TYPE OF EXISTING ROOF COVERING:
PROPOSED ROOF COVERING:
NU 14BER OF WMTINO ROOF COVERINGS REMOVED; 0
NUMBER OF EXISTING ROOF COVERINGS RETAINED: 0
PROVIDE I.C.B.O. REPORT NO. VALUATION: 700.00
IMPORTANT NOTICES NOTICE TO APPLICANT
APPLICANT'S CERTIFICATION
I hereby affirm under penalty of per)ury one of the follwaft declarations:
1 CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE I > I.
ABOVE INFORMATION IS CORRECT. I AGREE THAT IFA PERMIT 181&
SUED FOR THE DEMOLITION DESCRIED 18 THIS APPLICATION, ALL THE
PROVISIONS OF THE PERMIT AND ALL LAWS AND ORDINANCES IJI n.
THERTO WILL BE COMPLIED WITH.
HOLD HARMLESS CLAUSE. The permittee(s) by acceptance of the psmdL
agree($) be Indemnify and hold harmlaee the Chy, of Cupertino from and
against any and all claims, demands and actions for damages resulting from
operations under this permit regardless of negligence of the Cly of CupeMno
against all such claim, demands or actions. () pl
In conformity with the provisions of Section 3800 of the Labor Code of the ( )
$tats of California. the applicant shall hew coverage under (1), or (II) desig•
naiad below or shall Indicate Items (III), or (IV), or M. whichever Is applicable.
If however ham M Is checked Item (IV) must be cheekad se well. Mark the
aPPMOdate method of compliance.
LICFNBED CONTRACTORS DECLARATION
balan Tocol>wia°m�3"aMewn Codd Y1°n san:Mae ��ma'ne Amman ab MNlbaa� e t
sites
Lkwra s• 374573 Clan C36 RX; 05411/2001
PAYMENT
ACCOUNT!;
CREDIT CAR
W RE:
signature of Appnant w%gera DATE
I have and will mesnbdn a UnMpte of consent to aelNnalaa far workem' com-
pemadon, u provided by section 3700 of she Labor Coda, far the Performance
Of she work which this permit to Issued.
I lave irk will maintain werkm' cornponedtion baurence, as required by sea
Ilan 3700 of the Labor Code, for oa pMornanca of the wore no. which sire
Permit Is issued, My woemo7 compansedon Imurance amu and policy num.
dM
a STATE FUND
Polley Number 1516265
The cost of the work done is 8100 or leu
IV I artily that In the pedormeme of the work for which the pennn is blued, I
Ahab Rt Employ any person In any manner io as to become subjectto work•
aa' ampenaaon laws of CekNmia. I further acknowledge the[ I undmitond
that In the event eat 1 showed beams subleet to the warkere' compemadan
Provision& of the Labor Coda of CalBomie and NII a comply fonnwllh With
Prov alme of Seetim 3800 of the labor Code, that the Permit heroin applied for
mail be deemed revoked.
V. I cw* u the owner (or the agent for the owner) that in the I Wormanee Or the
work fbewNch this permit Is [,sued, I will ampley, a contractor who compass
with the wontere' oompensatien laws of Caamile and who. Pala to the mrf
mencement of any wont, will fire a complaW airy of this form with the Cenral
Parmnaureau,
EXPIRATIONDATE: 61'01
NAME ON CARO: ✓461AI a IL✓G C.&C
AMOUNTS:
.b"r/ L4
Painted Name of Applicant
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
• BUILDING PERMIT INVOICE OPERATOR: chrietya
Sec: Twp: Rng: Sub: Elk: Lot:37534022.00
INVOICE DATE......: 01/10/2000
REFERENCE ID # ...: 00010031
0
40
SITE ADDRESS .....:
10720 CULBERTSON DR
SUBDIVISION .......
CITY .............:
CUPERTINO
IMPACT AREA .......
OWNER ............:
ZIFF
ADDRESS ..........:
CITY/STATE/ZIP ...:
CUPERTINO, CA 95014
'
CONTRACTOR .......:
MCGEE, PAT LIC R 18986
COMPANY ..........:
WATER HEATERS ONLY
ADDRESS ..........:
500 AIRPORT BLV
CITY/STATE/ZIP ...:
BURLINGAME, CA 94010
TELEPHONE ........:
(415)349-3747
FEE DESCRIPTION CHR 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
�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
0
40