99070044 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY jO nQ
CITY OF CUPERTINO
BUILDING-ELECTRICAL � PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
OWNER'S N ME: PHONE: CONTRACTOR'S NAME: LIC NO: �l 2-
�(c
N/C CONTROL#
.�t lvi c'�- <<<'' �v '
RCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT_ PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
0 z z with Section 7000)of Division 3 of the Business and Professions Code,and my license is RESIDENTIAL:
O PERMIT ISSUANCE
F-W F in full force and effect. ❑SFDWL ❑KITCHEN REMODEL
U a [IElLicense Class Lic.#
Ln Q Date Contractor APPLIANCES-RESIDENTIAL ADDITION PLUMBING RE-PIPE
F�V) ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
z O to z I understand my plans shall be used as public records ! MODIFICATION
p 7�i Ca UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
QW Licensed Professional 201-1000 AMPS IMPROVEMENT ❑SWIMMING POOLS
yq OWNER-BUILDER DECLARATION
a' a OVER 1000 AMPS El BATH REMODEL/REPAIR El DEMOLITION
W Q I hereby affirm that I am exempt from the Contractor's License Law for the !
w F following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER '
W O rn which requires a permit to construct,alter,improve,demolish,or repair any structure - 1
d prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 �••{�{!�
(commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
0
WSection 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ElTENANT [IFOOD SERVICE
Zn noS more than five hundred dollars($500). IMPROVEMENT
I,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
C4 o
l do the work,and the structure is not intended or offered for sale Sec.7044,Business 1:1 OTHER
W 3 0o and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
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 NEW RESIDENTIAL ELECTR S
sale.If,however,the building or improvement is sold within one year of completion,the SQ.FT.FLOOR AREA $/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur-
pose of sale.).
E] 1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
construct the project(Sec.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 wih o
Licenntractor(s)licensed pursuant to the Contractor's
set,
Y PERMIT ISSUANCE
m
❑ I aea�pt under Pfd ,B&P C for this reason
'lw _ Date 2 C r'rT� ALTER-DRAIN&VENT-WATER(EA) ! VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE / r`
I hereby affirm under penalty of perjury one of the following declarations: V
❑ I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. DRIES TYPE CONSTRUCTION
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP ��PN
My Worker's Compensation Insurance carrier and Policy number are: i �. 9
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA) U. �'3
Z
CERTIFICATE OF EXEMPTION FROM WORKERS' /v/
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR I
(This section need not be completed if the permit is for one hundred dollars($100) 't '`I
or less.) GREASE TRAP PLANCHECK FEE
I certify that in the performance of the work for which this permit is issued,I shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to become subject to the Workers'Compen- ENERGY FEE
zZ sation Laws of California.Date WATER HEATER WNENT/ELECTR
C) Applicant GRADING FEE
i--i f%) NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/TREATING
(� ; become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
w �r forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FL PAID
U O I hereby affirm that there is a construction lending agency for the performance of Date Receipt#
w H the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL:
O ULender's Name
U Lender's Address TOTAL:
a I certify that I have read this application and state that the above information is BUILDING FEE
correct.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U Z building construction,and hereby authorize representatives of this city to enter upon the I SEISMIC FEE
~ above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgments,costs and expels which may in any way accrue against said City ALTER OR ADD TO MECH.
in con�gw
dce of the granting of thi'D tL PLUMBING FEE
:A1TLIZ;AN'IUU
NFRS"I'AND.S AND W LL(OMIT Y N'fflf \I 1,NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCI:'�tEGU1.,1F `I MECHANICAL FEE
'-ZC:- e AIR HANDLING UNIT(OVER 10,000 CFM)
"Y 1 CONSTRUCTION TAX
Signature of ApplicanUContractor T Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No PAID
VENTILATION FAN(SINGLE RESID)
Date Receipt#
Will the applicant or future building occupant use equipment or devices which
ut hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU)
,istrict? TO L:
F1 Yes F1 No �
BOILER-COMP(OVER 100,000 BTU)
AIR CONDITIONER
I have read the hazar u.materials requirements under Chapter 6.95 of the Cali- ISSUANCE DATE
t�mi lealth&Safety Code, ions 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL.MECH. SQ.FT.
bulWing does not e t y hav-•Tenant,that it is my responsibility to notify the occupant Q
of thelRquire fell, met prior to issuance of a Certificate of Occupancy.
i
ner or authorize age t Date TOTAL:1 ISSUED BY: F
OFFICE
IWiOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
BUILDING PERMIT INVOICE OPERATOR: karenb
Sec: Twp: Rng: Sub: Blk: Lot:37529037.00
INVOICE DATE......: 07/26/1999
REFERENCE ID # ...: 99070044
SITE ADDRESS .....: 18781 NEWSOM AVE
SUBDIVISION ......
CITY .............: CUPERTINO
IMPACT AREA ......
OWNER ............: SCOTT LEWIS
ADDRESS ..........: 18781 NEWSOM AVE
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
CONTRACTOR .......: LIC # *OWNER*
COMPANY ..........: SCOTT LEWIS
ADDRESS ..........: 18781 NEWSOM AVE
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
TELEPHONE ........:
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- --- --------- ------------ -----------
BPERMFEE P 77.00 0.00 77.00
BREMRECEPT P 2.22 0.00 2.22
BSEISMICRE P 0.50 0.00 0.50
EPERMITFEE P 35.52 0.00 35.52
--------- ------------ -----------
115.24 0.00 115.24
.E ID DESCRIPTION VOICE ID DESCRIPTION
101 FOUNDATION 102 PIERS
103 UFER 104 REBAR
105 ANCHOR BOLTS 106 SEWER & WATER
202 UNDERFLOOR PLUMBING 203 UNDERFLOOR MECHANICAL
204 UNDERFLOOR FRAME 205 UNDERFLOOR INSULATION
301 ROUGH PLUMBING 302 TUB & OR SHOWER
303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL
305 FRAME 306 HOLDOWNS
307 INSULATION 308 SHEETROCK
309 EXTERIOR LATH 310 INTERIOR LATH
311 SCRATCH COAT 313 ROOF NAIL
501 FINAL ELECTRICAL ENERGY 502 FINAL PLUMBING ENERGY
503 FINAL MECHANICAL ENERGY 504 FINAL BUILDING ENERGY
505 FINAL ELECTRICAL 506 GAS TEST
507 FINAL PLUMBING 508 FINAL MECHANICAL
509 FINAL GRADE 510 FINAL PLANNING
514 FINAL PUBLIC WORKS
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