30760 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 7/y��
CITY OFCUPF.RTINO BUILDING-ELECTRICAL PERMITNO. e] O 1 V O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
ro�ss
.B'S NAME: ID iSHONE: CONTRACTOR'S NAME: LIC NO: NPC CONTROL.
AMPICHIMCT/I.NGINFIER: LIC NO: ADDRESS: ❑
CONTACT. PHONE: q BUILDING PERMIT INFO
1 ❑ Consultant Fm Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
r ❑ a-1L ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby oftirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
QOZO wit Section 90011)uf Division Jofthe Dusinemand professions Code.md my license is PERMIT ISSUANCE S RESIDENTIAL
�F Iy homar Ca andeRat. ❑SFDWL C1 KITCHEN REMODEL
VFU titanate Clasx Con APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE.
zz LLl Date Cunvmnn
�n6a ❑MULTI-UNIT [I STRUCTURAL
h ARCHITECTS DECLARATION PANELS
Z O F/J 4Z 1 understand my plans ahall be used as purd
blic recos ^ '� MODIFICATION
❑
0z D UPT02MAMP5 L. INTERIOR ❑CHIMNEY REPAIR
r Licensed Prodconanal 201-1000AMPS IMPROVEMENT
5 � OWNER-BUILDER DECLARATION OVER1000AMPS ❑BATH REMODEUREPAIR [I DEMOLITION
�Pjj I hereby affirm 0wt 1 am exempt from the Contractor's License Law for the
LV following ro son.(Section 7031.5.Business and Pmfeasions Cerra:Any city or county SIGNS ELECTRICAL []OTHER
3 a EyQ' which requires a permit to construct,titer.improve,demolish,or repair any structure
C`0prim to in issuance,also requires the applicant for such Permit u file a signed statement SPECIAL CIRCUIT/MISC.
art IBM thatbeisRanged.alio..mthe pmvisinns.(me Conwetors License Law(Chapter 9 COMMERCIAL
(commencing with Seddon 9(10(1)of Dlvlsion 3 aide,Business and Pmfasaions Code)or TEMP.METER OR LE(NST.
6 a c that he is exemN therefrom and the basis header alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^ Section]031.5 by my tepplicttnd fora prsmit subjects to applicant to a civil penalty of R DEV ES ❑TENANT ❑FOOD SERVICE
�=alin not more than Ove hundred dollars 0500), IMPROVEMENT
❑I,mowner ol'Nc property,or my employees wit wages as their sole mmpctuetion. SWIMM G ELECT
Fa'Fq wdldo the work,and theamcturcisnm intended oroHered persdc(Sec.9044,Business ❑OTHER
a, end Professions Coda The Contractors License Law does not apply to nn owner of OUTL� -SW CHES-FIXT .S
property who builds or improves thereon,and who does such work himself m through
his own employees,provided that such improvements are not intended or offered for NE ESI AL ELECIR SQ FT.
sale.If,however,the building or Improvement is sold within one year ofemopletion,the SQ.PT.FLOOR AREA VSQ.FC
owner-builder will have the burden of proving that M did not build or improve for per- p�
, peaeofaale.). Y� B
as owner of the property,am exclusively contracting wit licensed contractors to lir
construct to project(Sec.7004,Bosine and Professions CmkO The Contractors Li--
cause
i- •`�
c se Lw does not apply to an owner of property who builds or improves thereon,and QTY. PL BI G E IT FEE
who contracts for such projects with a condmetant)licensed pursuant music Coatn mem ,H/`/9J6 DI'TT�
License Lw. PERMITISSUANCE A/Y lfll[[OO
❑laic axe tundtt Sec. B&PCfos tiarcnaon
ai,AALTER-DRAIN&VENT WA 'R(EA) ((rp�pTION
w cr Dam „,au
W
RKE^COMPEN. ION DEC.ARATION BACK PLOW PROTECT.DEV\E
I hereby a rat under penahy of pe jury one of the following dedaratlore -
Ihave and will maintain aCenificate of Conserv m wlf-inure for Workses Compen- DRAINS-FLOOR,ROOF,AREA,SQND. STORIES TYPECONSTRUCTION
sation,as provided for by S tion 3900 of the Labor Code.for the pMorimme m to
work for which this permit is issued TEXTURES-PER TRAP
n I have end will ratima n Workers Compensation ham..as required by Section
37M of the Latour Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLIiTS OCCGROUp APN
My Workers Compensation Insurance carder and Policy number ore:
Cartier, Policy No.: GAS-FA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE. GREASI%INDUSTRL WASTE INfERCEPTOR BUILDING DIVISION FEES
(This section need not be completed ifte permit is foram hundred dollars pH00u GREASF.TRAP
or Ir..)(This
FEE
I certify that in the performance ofthe wrkfor which this permit is issued,l shall SEWER-SANITARY-STORM HA.200 FT.
not employ any peon in any manner m in to become subj.,o the Workers'Co.,.-- ENERGY EEE
O ,� sation Laws of Colionain Data WATER HEATER W/VENT/FLEC R GRADING FEE
7 O Applicant
G NOTICE TO APPLICANT if.oiler making tis Cur ificarc of Exemption.you should WATER SYS'fEWDUEATING SOILS FEE
a; become subject o the Worker's Compensation ptavisimna of the Labor Code,you must
{II forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
aQ
UO CONSTreRUCTION LENDING AGENCY NLW RESIDENTIAL PLMN. ' SQ.pC PAID Date Receipt0
I hereby affirm that tete is sued(See.30lending agency for the peRormameaf
F the work for which this permit is issued(Sec.31192 Civ.C.)
{2r fender's Name TOTAL:
L) Lndcrs Address TOTAL:
aI testify that I have read this application end smic that to above information is BUILDING FEE
�+V2 colica.I egret R.comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U ,Z building construction.=it hereby autonze representatives oftis city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
1. (We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilitieajudgmenta.coasand aspenaea which may in anyway same against mid City ALTERORADDTOMECIL
me onmquence of to granting of this permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL ME
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
Signature of ApplicamsConaacmr Dae EXHAUST HOOD ONMUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hamrdous material HPATING UNIT(TO 100,000 BTU)
as defined by to Catania.Municipal Cate,Chapter 9.12,and the Health nod Safety
Code,Scene.2553200? HEATING UNIT(OVER I11U,0110 BTU)
❑Yes 1`1 No VENTILATION FAN(SINGLE RESIDE PAID
Dam Receipt
Will the applicant or fulnre budding occupant use equipment or devices which
:d t hazardous air exam mimnts as defined by to Bay Area Air Quality Management BOILER-COMP(JHP OR IOO,g10 BTU) TOTAL:
'sniat9 BOILER-COMP(OVER 100,U)0RTU)
❑Yes Fl No
E have road the hazardous materials reru Cements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 25505,25533 and 2.5530.I undersand tat if the NEW RESIDENTIAL MI CH. SQ.ET. '
building docs not currently have a tenant tat it is my responsibility to notify the occupant
of to requirements which must he met part in issuance of a Certificate of Occupaay.
Owner or autanzed agent Data TOTAL ISSUED BY:
OFFICE
r�l�
. l
R® ' 10300 Torre Avenue
(�ilc
Cupertino,CA 95014
Citpel-tlllo Building Division
(408)777-3228
(408) 777-3333 (fax)
September 30, 1997
�, O
Homeowner 4 1
Bro
Cupertino,
ino, CA
/
Cupertino, CA 95014 , C
SUBJECT Permit#30760 > � J
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 rk
Pnn:ec on Rocvdad Paper