S 1953APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELEC'I'RICA], 1'E IT NO.
BUILDING DIVISION APPLICATION/PERMITn PLUMBING ;MECHANICALT y 195 3
CONTACT:
I' ONE: CONfRAI
❑ Consu drain Fees Paid by Applicant (Initial)
of
QTY ELECTRIC PERMIT
hereby atlinn that 1 tun IiamseJ under pmvi ions Chnpmr 9 (commencing
wish So,non700()of Division3oflhe Busiamcsaal Professimu Cedc, an,mylicense i.
BUILDI FEE —
in full force azul elfeet. 1%
PERMIT ISSUANCE
Liap
RIC vrE
DaZv
Dae Comracmr -
APPLIANCES — RIrSIDWI'IAL
ARCHIT .CTS DECLARATION
EC ANICAL IPE
IanJersa my Ian: h sed un public rcmrJs
PANELS
UP TO 200 AMPS
OWER -BUILDER DECLARATION
1 hereby affirm that I a empt from the Contractors Lianne Law for the
following reason. (Section 7031.5 eBusiness and Professions Code: Any city or county
which re moo,i a permit m comfort, alley, improve, demolish, or repair any structure
Prior to its issuance, also requires the applicant for such Permit o file a signed statement
that he is liansed poseanl Io the provisions of the Contractor's I iccuse Law 1Chop er 1)
(commencing with Section 7000) of Division 3 of the Business and Prnfesinns Code) or
that he is exempt therefrom and the basis for the alleged exemption, Any violation of
Seed.... 703IS by any upplintm fora permil subjects the appllcwl m o let I+cnaltyof
not more Ihan five hundred dollars (5500).
0 I, as owner of the property, or my employees with wages as their sole compensation,
will Jo the wnrk. and the seder, ante intended or offered for sele(Sec. Two Business 3
and Professions Code: The Cantmaor's License Law does not apply to an owner of
property who builds ter improves thereon, and who does such work himself car hrough
his own employees, provided that such improvements are not intended or offered for
sale. If, hmveven the building or improvement is sold within one year of completion, the
cr-builder will have the harden of proving that he did not huild or improve for p.r-
,sc of sale.).
0 1, as owner of the propeny, am exclusively contracting with liansed comracmrs m
construct the project (Sec. 7(44, Badness and Profession, Cod, one—nu o......
cense Law does not apply to sen owner ofpropeny who builds or improv, thereon. and QTY,
who contracts for such Projects with o commercials) licensed pursuant o the Contractors
License Law. ,
El I em exempt under Sec. ,B& to C far this rersnn
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or to mm building occupant pore or hand to haaardous material
as defined by the Cupertino Municipal Cole. Chapter 9.12, and the Health and Safety
Code, Section 25532m)?
0 Yes
Will the applicant or future building occupant use emipmenl or devices which
mil hamrdnas air emotional s eGned by the Bay Area Air Quality Management
DiancO
0 Yes
1 haver J the hmallo anals requirements under Chaplet 695 of the Cali -
Pon
: fct GoJI crucas 25505, 25533 odd 25500.1 understand that if the
buildingdoe rnct :ly_c comm dal it is my mspansihilil mnmify the occupant
of the o c of Toone lsu referee of Occupancy.
OVER IIXNIAM S
SIGNS ELIiCfkICAI
SPI!CIAf. CIRC
TEMP. MLTER OH I'OL. SLLT
PDWIiR DI!VICES 'l
SWIMMING POOL F.LE IC
OUTLETS — SWITCHES — FIX
NI!W RESIDENTIAL ELECTR
ALTER — DRAIN h VEM— W
BACK FLOW PROF ECT. DEVICE
DRAINS — FLOOR, ROOF, AREA, COND.
FIXTURES —PER'1'RAP
GAS— EA.YS
STEM -1 INC. 4 OWLHES
GAS — F.A.SYST V-NVER 4 UJ
SQ ET.
GRF.ASETRAP s
SIiWER —SANIT Y-5'1Y)RMBA.200FT.
WATER SERVICE
NEW RESIDENTIAL PLMM, SQ. FT
MECHANICAL PERMIT
PERMIT ISSUANCE 3
ALTERORADDTOMECH. /
AIR HANDLING UNIT ITO 10.01 CFM)
AIR HANDLING UNIT (OV HR I0,I00 CPM.)
EXHAUST HOOD(W(DUCn
Hlz.xrING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER I (0!1011 if'IU)
VENTILATION FAN (SINGLE RESID)
BOILER— COMP (3HP OR 111(1.0191 BTU)
BOILER —COME (OVER 11X1 Bre BTUI
AIR CONDITIONIR
NEW RESIDENTIAL MECH. SQ. PC
y -1K-
1
1i
1 M9 y
UQ BUILDING PERMIT INFO
BLDp ELECT PLLUUMIB MEEECCIH
IVI11cT — /iYl OL A -
PEE JO(B/DESCRIPTION -
RESIDENTIAL
C SFDWL C KITCHEN REMODEL
CADDITION ❑PLUMBING RE -PIPE
El MULTI -UNIT CS7'RUCfURAL
MODIFICATION
t4ITERIOR ❑CHIMNEY REPAIR
IMPROVEMENT L] SWIMMING POOLS
C BATH REMODELIREPAIR 0 DEMOLITION
C OTHER
COMMERCIAL:
EWBLDCADDITION ❑DEMOLITION
TENANT ❑ FOOD SERVICE
PROVEMENT
❑ OTHI7R
SQ. FT. FLUOR AREA I SLSQ. FT.
FEE
LJB✓LIL—
�C7'DO-P
ST/DRIES
TYPE L NST6 RUCTION
Zr-i Af
11357-W-ca5
BUILDING DIVISION FERS _
PLANCHECK FEE d V
ENERGY FEE
GRADING FEE
SOILS FEE
Owner Date
WORKER'S COMPENSATION DECLARATION
BUILDI FEE —
FEE
1 hereby affirm under penalty of perjury one of the following declarations:
rblot
RIC vrE
❑ Ihave unl will muinmin uCenifeatc of Consenun self-in.wre fur Wnrke6 Cnmpem
BING FEE
sation, as provided for by Section 37M of the labs Cade, far the performance of the
EC ANICAL IPE
k for beholds permil is issued.
haveand will maintain Worker's Compensation Insurance, as required by Section
W e Labor Cole, for the performance ofthe work for which this permit is issued.
IDoc Be
My Work, '' Co tiyr�It��w�M orrlur and Policy nu ��rak� .�,p� QQ
Currier: NNYec
r
Policy Na.:ry
CERTIFICATE OF EXEMPTION FROM WORKERS'
ISSUAN
� t
ISSUED BY:
COMPENSATION INSURANCE
(This section need not hceumpleted if heartland is tmone hundred dollars(5100)
or less.)
I cervi ly Ort in the pormoomm c of the work Inc which this permit is Ixmed, l shill
Qz
z
not employ any person in any manner not as to become subject to the Worker.' Compen-
soon. Laws of Call fnmia Date
Applicant
.N..
a,
C Q
ice. z
G O
fY F
NOTICE TO APPLICANT,If. after making this Cenificare of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such previsions or Ibis Ixrmit shall be Deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that hem is u construction heading agency for the performance of
the work far which this permit is issued (Sec. 3097, Civ. C.)
L Name
Ucoda's
Q
ULender's
L1r
Fr y
U z
Address
1 certify that 1 have read this application and state that the above information is
coact. 1 agree to comply with all city and county ordinances and state laws relating is,
building mnstmaion, end ho,im m ae mpremnmtives of this city mercer upon the
nhnvo-mentioned prop yfminsp¢ on pugmsea.
(We) agree mc, indent and keep harmless the City of Culwninn against
QTY.
5
linbilities.judgmem <�[{sn ande seswhich may in any way seems against said City
asequence of min l uperook.
AI'PLICART U DI31 ST S 1Np WILL COMPL - L NON -POINT
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or to mm building occupant pore or hand to haaardous material
as defined by the Cupertino Municipal Cole. Chapter 9.12, and the Health and Safety
Code, Section 25532m)?
0 Yes
Will the applicant or future building occupant use emipmenl or devices which
mil hamrdnas air emotional s eGned by the Bay Area Air Quality Management
DiancO
0 Yes
1 haver J the hmallo anals requirements under Chaplet 695 of the Cali -
Pon
: fct GoJI crucas 25505, 25533 odd 25500.1 understand that if the
buildingdoe rnct :ly_c comm dal it is my mspansihilil mnmify the occupant
of the o c of Toone lsu referee of Occupancy.
OVER IIXNIAM S
SIGNS ELIiCfkICAI
SPI!CIAf. CIRC
TEMP. MLTER OH I'OL. SLLT
PDWIiR DI!VICES 'l
SWIMMING POOL F.LE IC
OUTLETS — SWITCHES — FIX
NI!W RESIDENTIAL ELECTR
ALTER — DRAIN h VEM— W
BACK FLOW PROF ECT. DEVICE
DRAINS — FLOOR, ROOF, AREA, COND.
FIXTURES —PER'1'RAP
GAS— EA.YS
STEM -1 INC. 4 OWLHES
GAS — F.A.SYST V-NVER 4 UJ
SQ ET.
GRF.ASETRAP s
SIiWER —SANIT Y-5'1Y)RMBA.200FT.
WATER SERVICE
NEW RESIDENTIAL PLMM, SQ. FT
MECHANICAL PERMIT
PERMIT ISSUANCE 3
ALTERORADDTOMECH. /
AIR HANDLING UNIT ITO 10.01 CFM)
AIR HANDLING UNIT (OV HR I0,I00 CPM.)
EXHAUST HOOD(W(DUCn
Hlz.xrING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER I (0!1011 if'IU)
VENTILATION FAN (SINGLE RESID)
BOILER— COMP (3HP OR 111(1.0191 BTU)
BOILER —COME (OVER 11X1 Bre BTUI
AIR CONDITIONIR
NEW RESIDENTIAL MECH. SQ. PC
y -1K-
1
1i
1 M9 y
UQ BUILDING PERMIT INFO
BLDp ELECT PLLUUMIB MEEECCIH
IVI11cT — /iYl OL A -
PEE JO(B/DESCRIPTION -
RESIDENTIAL
C SFDWL C KITCHEN REMODEL
CADDITION ❑PLUMBING RE -PIPE
El MULTI -UNIT CS7'RUCfURAL
MODIFICATION
t4ITERIOR ❑CHIMNEY REPAIR
IMPROVEMENT L] SWIMMING POOLS
C BATH REMODELIREPAIR 0 DEMOLITION
C OTHER
COMMERCIAL:
EWBLDCADDITION ❑DEMOLITION
TENANT ❑ FOOD SERVICE
PROVEMENT
❑ OTHI7R
SQ. FT. FLUOR AREA I SLSQ. FT.
FEE
LJB✓LIL—
�C7'DO-P
ST/DRIES
TYPE L NST6 RUCTION
Zr-i Af
11357-W-ca5
BUILDING DIVISION FERS _
PLANCHECK FEE d V
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Um• c
BUILDI FEE —
FEE
SE15 'FEE
rblot
RIC vrE
C) O
BING FEE
EC ANICAL IPE
NUCTIONTAX
�)NS
qyu Sl G MITIGATION EEE
IDoc Be
r
ISSUAN
� t
ISSUED BY:
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL PE 11 1.
'.Z
BUILDING DIVISION APPLICATION/PERMIT mG
PI,UMB-MECHANICAL `�'•
RI II LIVING PRO I ECT IDENTIF'IC\9'ION
KV-111raeo 11�� (I, ,2
mil
fE NS a�
/Ss.
❑
RCFIyJ:CfENGINEEy: LICIO
V CO�!
ADD7EESS
•N`
'ONACT: PHONE
BUILDING PERMIT INFO
—o+❑
33
Consultant Fees Paid by Applicant (initial)
BLDG ELECT PLUMB MECH
woZ
F'
W-
aUV
I- a W
=IolSDECLARATION
Z O,�„Z„
9 Z,—�
FN61
=W,
�0. o. V
LICENSED CONTRACTOR'S DECLARATION
1 hereby infirm that 1 am licensed under provisions of Chapter 9 (commencing
Ib Section IIXx) of Di vision 3 of the nosiness and Professions Code. and my license i.
u 674162
License Clxc.p C
n�
a fall force and effectk1u,cilie,ablitnerrad,
nam C' 'a'
IundemmrJm
QTY ELECTRIC PERMIT FEE
_
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL ❑ PKIT LUMBINHEMODEL
❑ADDITION PLUMBING RE -PIPE
❑MULTLUNIT ❑STRUCTURAL.
MODIFICATION
[I INTERIOR C1 CHIMNEY REPAIR
IMPROVEMENT C]SWIMM ING Pi
OOLS
ElBATH RFMODEUREPAIR (l DEMOLITION
El OTHER
PERMIT ISSUANCE.
APPLIANCES-RESIDENTIA1.
PANELS
UPTO200AMPS
Licensed Profession
OWNER-BUILDER DECLAItNOGN
I herehy union that 1 am exempt from the Commcmr's License Law for the
following reason. (Section 9031.5. Business and Professions Code: Any city (it county
201-1000 AMPS
OVER ❑xx1AMPg
SIGNS ELECTRICAL
OI"
61 LL
F. a�
W.^^
which requires a permit to construct, alterimprove, demolish, or repair any xtmcutre
PH.". as issuance, also re,moi the applicant for such Permit to file a signed statement
1bar he is licn rd pursnanl to the PmvWons of the Contactors License Us. (Chapter 9
(commencing with Section 9xxB of Division 3 of the Business and Professions CodcHv
SPECIAL CIRCUIT/MISC.
TliMO Mlii'ER UR Pou31NS'1'.
COMMERCIAL; J/,.�][
0. 0 k_y�Il
W
N,
xzQ
ESO
p.
0. 3 m
that he is exempt drinfimm and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the uIllumatre avillwnalty of
sol more than five hundred dallan(S500).
I, as owner of the norm loee.s with woes un their sale cote tion,
PnWe a YcmP Y 6 ,ensu
will M lhework, and nh Cot is mors Lienee owdoes sale .,apply 70,14, Business
and Rofessionx Cale: The Counselors License Low Jces nal apply m an owner of
property who huilds ur improves therein, and who does such work himself or Nrnugh
his own employees. Provided that such improvements arc not intended or offered for
sole. IL however, the building or impmvemem is solA within one year nfconmlerion, the
❑ NEW BLDG/ADDITION CI FO 1t SERVN
❑TENANT ❑FOODSERVICE
IMPROVEMENT
❑OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS — SWITCIIIS— FIXTURES
NEW RI?SIDEN'll til �L: R SQ IT.
SQ. FT. FLOOR AREA
USQFIL
woe -builder will havv the madcr of proving that to did not build or improve far pur-
poseofsvle.}
1, as owner of the Property, um exclusively contracting with licensed commcmn to
TOTAL:
consumer the project (Sec. 70,14, Business and Pmfessinm Cde:)'I he Contractor '% Li-
cense law docs nm apP1Y m an owner of ,merry who builds or improres Ihercon, and
QTY. PLUMBING T FEE
who contacts fart such Projects with it comm corp) licenmd pursuant to the Cammetur'%
PHRMI'IISSUANCE
License Law.
❑ I am exempt under Sec .B& P C fur this ..on
NITER—DRAIN&VIiNT—WATT (Ii
VALUATION
Owner Date
ON
DECLARATION
WORKER'S COtyoi
BACK FLOW 1'H(YTECf. DEVICE
DD p/1
folio
I hereby affirm under rye�ity nl perjury one of the following declarations:
acua, on
l%
TORIES
TYPE CONSTRUCTION
(have and will maintain aCmihcate ofConunum self-insurt for Workers Compen-
shoo, as pno,Idel for by Scenes 37110 of the Labor Code, for thu Pcrformunc r of the
in hichlhispermitisissued,
IlRA1N5—FLUOR. POOH AREA, GOND.
19X'1'URES—PER THAI'
and will mainmin Workers Compensation Immrance, as arearsd by Section
370t]tu1Th,I.vMm Calgfonl}jperlormanm ol'Ihc work for which Ibis permit is issued.
Carer:_�I�Peymn4hurap�camier and Policy numJ��err,�/fyj�
Carrier: Policy No: �i
GAS—RA.SYS'TEM-IINCAOUTLFTS
OCCGROUp
�
APN
n^
3 u%
GAS —M.SYS'fEhl-OVBRJ(FA)
F
<)
FSATIONINN PROM WORKERS
CERTIFICATECOMPENSATION
COMPENSATIONINSURANCE
('1'hi,,atinnncWnotbocomplcted""eperait is for one hundred dollars($100)
nr lees.)
GREASL%INDUSTRL WASTE IN rERCF.I'TOR
BUILDING DIVISION FEES
GREASE TRAP
PLANCHECK Niili
SEWER—SANITARY—STORM EA, 20 FT.
fiNERGV FEE
z
I cenity thin in ThepeHorminceoftheworkfor whichthilpermit is issued, l shall
not employ any penin in cry manner mto so as to becne object the Worker%' Comers-
A pplicanit.. La's of Califnmia. Date
WATER HEXUR WNENT/F.LECTR
GRADING FEE
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
Fortune, subject to the Worker's Compensation provisions of the Labor Cale, you must
comply with such provisions or this smirt,hah be d,creedosokW.
CONSTRUCTION LENDING AGIiNCV
l hereby affirm that There is a construction lending agency fort beperinnnanceof
the work for which This pernL is issued (Sec. 3097, Co, CJ
Lenders Name
WATER SYSIlIaREATING
SOILS FEE
y
F' ?
Wforthwith
a
5z
L) 0
W
O U
WATER SERVICE
LAID Date Receipt
NEW RESIDENTIAL PLMB. SQ. FL
TOTAL:
TOTA L:
BUILDINGVF
ISI
Ly,
C.t fatl
Uz,
Landers Address
I cenify the I have read his application and stem that the above iofornsiob is
correct. l agree to purply with all city and county ordinances and wale laws rehong m
laiddingconslreeien. an creby amhoriu mpreunmtives of miscity to enmrupnn the
QTY. MECHANICAL PERMIT FEE
SIISMIC F
PERMIT ISSUANCE
IiLECfRICies,ju
uMwc-memioned,ropes far imp ;'Can par acs
(We) grw to sa ,indemnify send keepharmless The City of Cupcnino against
PLUMPINemsearmc
mems, hich may in any way accrue against said City
ALTER OR ADD TO MECH.
of th mt.
APPLICA T IN -TLL C(IMPLY WITI{pLL NON-i'OINT
pIR HANDLING UNIT (TO IO,IXM)CFM)
h1ECHANIOURCE
EC '.ATI MS.AIR
HANDLING UNIT(OVER 10,000 CFM)
CONSTRU`
EXHAUST HOOD(W/DUCI')
HOUSING MITIGATION FEF.
Sign sere( APplicm Con Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant nr future tuildi,evetpanworc m handle hazardous mmedid
as dented by the Cupertino Municipal Cndc, Chvpter 9.12, and mm !{euhh sad Safety_
Cala Set 25532SY
i]Ycs'
HEATING UNIT OV 100,000 BTU)
OF l NO UNI 'f(OVER 1(x1,1100 BTU)
er
PAID
DI)d IC t ' Hcaipl M
VEN'IILA9'ION PAN (SINGLE RF?SID)
Will the replicas or future building occupant use cyuiptcem or devices which
miI laconic., air contaminants as defined by dee Bay Arca Air Quality Management
Incl,
BOILFiR — COMP (311P OR 100,000 BTU)
TOTAL:
8011.138—COMP(OVER 1(p.IXI RTU)
(]Vas
AIR CONDITIONER
ISSUANCE DATE
(have ad,meaneril% hunder Chapter 6.95 of the Cali
quimm nHell y Calons 255(15, 255)3 and 25534. I understand that it the
funi
NEW RESIIl1iNT1AI. MSCI I. SQ. Ff..�
building J: ❑ybave utcnanI, that it is my responsibility m notify the occupant
of the re r m% vh must M met Prier Io issuance of a Cemifi<am of Occupancy.
Ownermm oris% agent Dare
L��.�]`��\__•,,t� //YX
ISSUEDBY: _LLTIUV ��
TOTAL:
OFFICE
u
of
10300 Torre Avenue
Cupertino, CA 95014
Building Division
1
(408) 777-3333 (fax)
March 5, 1999
Property Owner
10161-A Bubb Road
Cupertino, CA 95014
SUBJECT: Permit # S1985
Dear Property Owner:
We have been going through our files in the Building Department, and contacting those
people with permits remaining "open".
According to our inspection records, this permit has not been signed off by the Building
Department. 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 remove the records from our computer.
Thank you for your assistance.
Sincerely,
CITY OF CUPERTINO
Christy Akatiff, Administrative Clerk
Printed on Recycled Paper