30046 APPLICAIajTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT.PEN ONLY _
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 3 O O A T O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: z SANITARY NO. APPLICATION SUBMITTAL DATE
ni NE ;CO - � 4" �
.+ OWNER' NAME: VHONE: CONTRACTOR'S NAME: LIC ND.
lu-Saaq
6AjSl� 7N/C CONTROL q
\RCHITECP/ENGUJEER: LIC NO: ADDRESS: -1 ❑
3353
NTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSEDHimIamCONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 herby affirm Nat I am licensed under provisions ofChapterCode, 9(commencing ]OB DESCRIPTION
�a'Z with Section]0011)ofDivision JnftheBusiness and Pmfessiona Cade,and myliccnxc's
X00 PERMIT ISSUANCE RESIDENTIAL:
F-� L ane Clan:1 Rect l" _C0 '�!/ ❑SFDWL ❑KITCHEN REMODEL
�Uf
License Clan:71 T� )t�
F< V APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING 0.&PIPE
Vs Q 6 Date Cuntrm:mr
P
on ARCHITECTS DECLARATION PANELS ❑MULT6UNIT ❑STRUCTURAL
f❑.. I understand my plans shall be used as public mounts MODIFICATION
ZOx-GUPT02(a AMPS ❑INTERIOR ❑CHIMNEY REPAIR
P,4I:; Licensed Professional 201-1000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER 1001)AMPS ❑BATH 0.EMODEI/REPAIR ❑DEMOLITION
o w< 1 hereby aff that I am exempt from the Contractors Licenm Lmv far tic
gxO6U fallowing moon,(Section 10313,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
t+r LLD y which requires a pctmut to construct,alter,improve,demolish,or repair any,sventre
prior o its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
ythat he is licensedpursuemtothep�ovisionsoftheCnmmnur'aLicenseLaw(ChupmrY
��� (commencing with Section]OfXq of Division Sof the Husinea and Prnfasiom Cude)ar TEMP.METER OR POLE INST. COMMERCIAL:
2 o C that he is exempt therefium unit the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION 0 DEMOLITION
.tar m Section 7031.5 by any applicant faro permit subjects the applicant a civil perry o1 POWER DEVICES
not mum than five hundred dollars S500). ❑TENANT ❑FOODSERVICE
H Z Y IMPROVEMENT
Q wi l,00wner of Ne pmpeny,or my employos with wagsotheir sole compensation, SWIMMING POOL ELECTRIC ❑OTHER
W;= will do thcworicn;Cuba:Twctuma tots Lice sur Law
di a of apply to an Business
3 m and Profession Code:The Conveereo License Law does not apply to if owner of OUTLETS-SWITCHES-FlXT
hproparyis own who builds or improves thertaq and vwhoem does such work himself or through
his own employes,provided that such mentis old within thin nm intended or plcod fur NEW N[SIDENTIAL EL[CTR -
owneT-however Ne by the bur en of p mens is at hedd one build
at i provemfor the SQ.FT.F1002 AjEp� 5/SQ.PT.
serf Wa.er will have the burden of proving that he did not build err improve for par- V
pose of site.). r
I,ruowner ofthe property,am,( exclusively contmming with I�a, cotwcam AL: 96
cone La the es net apply
pl(Sey to an Business and property
wh ims,builds
CakJ The Convectors Li ®v Q 19
nu Lawdoes
such plytoan with
aofpropeny whosedporimpmvee thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a contractors)licensed pursuanuo the Convenors
License Law. PERMIT ISSUANCE CIyIv t (;UH` LIN
1'um exempt under Sec. ,B&P C for this raison 1 U
Owner
ALTER-DRAIN&VENT-WATER IEA) VALUATION,
UIte
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE ,
I herby aR under panainyof ofCommiatotheinsum for decimations:
(have and will for bynetion 37M of one Limon sodc,heare for Worker's Camper-of h- GRAINS-FLOOR,ROOP.AREA,COND. STORIES TYPE CONSTRUCTION
as provided far mi Section J]W of one Lobar Cude,for the performance of the
work for which this maintain
tiis issued FIXTURES-PER TRAP
1 have and will maintain Workers Compensatimm Insurance,as required by Section
3]W of the Lobar Code,fonhe per me canceuf nth<work Gri which Nis pemrim ie
issued. GAS-EA.SYSTEM-1 INCA OU'RGfS - OCC GROUP APN
My Workef C�1{gmnpensetion Inc unec artier and Policy nyryfy
Cartier. LLhssel Paid
No.aY/ �� GAS-M.SYSTEM-OVER 4(M)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE OREASEANDUSTRL WASTE INTERCEPTOR
(This section need nit becompleted ifthe permit is fosse hundredd.11.(S I W) BUILDING DIVISION MES
lessd GREASETRAP PLANCtIECK FEE
I rectify that in the performance of the work for which thicpermit is issued,Ishall SEWER-SANITARY-STORM EA.2W ET.
not employ any person in any manner sa as to become subject to the Worker.:Compcm ENERGY FEE
zZ sours Laws of Celifomia.Date WATER HEATER W/VENT/ELECTR
Q Applicant GRADING FEE
y NOTICE TO APPLICANT.IL He,making this Cenifmate of Exempdon,you should WATER SYSTEM/1'REATING
a ; become subject to the Worker's Compensation provisions of Nedmus
e Labor Ce,you t SOILS LLE
i..� foMwith comply with such provisions or this Fenm
dt shall be deemed evoked. WATER SERVICE'
0. Q
U Z
CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID Date Receiptg
U O work
f which
thi that Nerc is a ed((..'3097,on Cis,agency for the performance of
W H Lffice work for which thio permit is lamed(Sea 309].Civ.CJ
O U Lender's Name - TOTAL:
Lenders Address TOTAL:
y 1 certify that I have mad this application and state that the above information is BUILDING FEE
h carrot.l agree to comply with all city and county ordinances and sum laws miming to QTY, MECHANICAL PERMIT FEE
U Z building construction,and hereby auNoAu representatives of this city in enter upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSDANCE
(We)agree to save,indemnify and keep hamdess the City of Cupmina against ELECTRIC FEE
Iiabilitiea,judgments costs and expenses which may m any way attmeoghimtsuid City ALTER OR ADD TO MECH.
in asequence of the gmming of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IB,BOBCFM)
SNE. EGULATIO MECHANICAL FEE
- AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
Signature cd ppn'"Ins'ntr err Dam EXHAUST HOOD(W/DUCD HOUSING MITIGATION FEE
HA ZA OUS MATERIALS DISCLOSURE
Will the epplicamo uture building oecupwtamm or handle hamNuus materiel ` HEATING UNIT(TO 1W,W8 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade.Section 25532(ap HEATING UNIT(OVER 100,IXq PTU)
❑Yes 0 N PAID
VENTILATION FAN(SINGLE ftPSID) Data Receipt g
Will the applicant mbuilding occupant use equipment or device which
at haraNum air communicant as defined by Ne Bay Area Air Quality ManegcrManagementBOILER—
COMP(JHP O0.100.0130 BTU)
OTAL:
cost? BOILER—COMP(OYER I W,(Xp BTU)
❑Yes ON.
I have read the Incardousmauriats requirements under Chapter 6,95 o1 she Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 25505,23533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.ET.
building does not aummly have a manual,that it is my responsibility m nmify the occupant
of the rry urcum is which must be mcn prior m I...of u Certificate of Occupancy.
Owner or authorized agent Data L. ✓ ISSUED BY:
OFFICE
Ptlperth�o
10300 Torre Avenue
i. Cupertino,CA 95014
Building Division
(408)777-3228
(408)777-3333 (far)
June 18, 1997
Homeowner
10191 N. Blaney Avenue ! >
Cupertino, CA 95014
SUBJECT Permit#30046
Dear Homeowner:
We have been going through our files in the Building Department, and contacting those
people with permits remaining"open:
According to our inspection records, the subject permit has not had a final inspection.
Many times an inspector will sign the permit in the field, but overlook reporting all of the
information to the clerical staff for input into the computer. If this is the situation and
your permit card shows the final sign-off,would you please contact us so we may
complete our computer records?If the permit is not signed off,please call to schedule an
inspection for final closure of the permit.
Because of the large volume of paperwork within the building department, we cannot
separately monitor the progress of each permit. We ask that you give this notification
your immediate attention. If we do not hear from you within ten(10) working days, we
will dispose of the file and remove the records from our computer.
Thank you for your assistance.
Sincerely,
CITY OF CUPERTINO
Christy Akatiff, Administrative Clerk
Printed on Redvdled Paper