30053 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES,-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. 30053 O O S2
V
ILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECIIANICAI, 3
BUILDING PROJECT IDENTIFICATION
UILDINGAUURFSS: - SANITARY NO. APPLICATION SUBMITTAL DATE
D M D09 t,15-,Y IgE . Z -/3-S G
O 1111N),111: O NE:� C RA R' NAME: LICN
NIC CONTROL If
ARCHIM ENGINEF;R: LICNO: UDR.SS: - ❑
v aJE
CONTACT: PHONE: BUILDING PERMIT INFO
35* _( ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUME MECH
—li %{ ❑ ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION
F1 QTY. ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9 my license is JOB DESCRIPTION
D a'Z with Section 70018 ofDivisionl.fthc Business and Professions Calc,and my license is RESIDENTIAL:
in full force and,feel. PERMIT ISSUANCE
;0: ❑SFDWL El KITCHEN REMODEL
4a� License Class Lia# tor APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
y Dale TSDCiontCL
ARCHITECTS DECLARATION ❑MULTLUNR ❑STRUCTURAL
z O m 4 1 understand my plans shall be tied as public records PANELS MODIFICATION
Oz-F,r UP TO 200 AMPS El INTERIOR El CHIMNEY REPAIR
r In Ip- sensed Professional 201-IIMIOAMP$ IMPROVEMENT
Sas 5-1 OWNER-BUILDER DECLARATION
yy a 6611 I bertby affirm that I am exempt from the Contractor's License Law for the OVER BMIAMPS ❑BATH REMODEUREPAIR [I DEMOLITION
bd a d C-) following mnson.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL' []OTHER
i
YY1l y O p- which reyui
LLms a Vcrmh m mmwcl.elm,,improve,demolivh m repair any atrucome
prior to its issuance.also requires the applicant for such Permit in file a signed statement SPECIAL CIRCUIT/MISC. s
pnerthat he is licensed pubmano Ne provisions of the Contractors License Law(Chapmr9
00 tt(omposaaing with Section700H.111,tais.30(he Business and Professions Gsde)or TEMP.METER OR POLE INS . COMMERCIAL:
p e' that he is exempt merchant and the basis for me alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
iy� V• Sion 7031.5 6y any applicant for a pm
edt subjects me opplicam m a civil penelry of POWER DEVICES
uI^m ect ❑TENANT ❑FOOD SERVICE
FCt more man five handled dollars(5500). IMPROVEMENT
(] I,ae owner of the progeny,.nny employees wire wngee as their sole compemntion, SWIMMING POOL ELECTRIC ❑OTHER
will dome work,and the saucmre is not intended proffered Torsade(Sec.7044,Business
Ul and Professions Cade:The Convectors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
6 3 prepeny who build,or improves flare..,and who does such .,it himself or through is g
his own employees,provided that such.improvements me not intended or,offered rot NEW RESIDENTIAL ELECTR FT. ^
..It,If.however,the building or improvement is sold within one yrarml completion,me SO.FT.FLOOR AREA $/SQ.FT.'
owner-builder will have the burden of proving that he did not build or improve for Eput.
pa asowner
❑ JUN 131996
wnerof the Property, lusi
excvely contracting with contractors m ructursAL.
' ccollateralacollateralthe project ISec.7044,Business anJ Profession Code)The Conwaor's Li-
censclaw does not apply to an owner of property who hands or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts m
sfor such projects with a cpmemds)licensed pursuant to the Commemrs v'-� Ur Vys LfsilltlJ
s License Low. - PERMIT ISSUANCE
C]1 em exempt under Sec. ,B&P C for this mason'
Owner Dale ALTER-DRAIN&VENT-WATER EFA) VALU111Li
WORKER'S COMPENSATION DECLARATION D�•-1/
Iherb offtna under BACK FLOW PROTECT.DEVICE. C/
y penally of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consenu.self-insure for Workers Camper- DRAINS-FLOOR,ROOF,AREA.COND.
RIES TYPO CONSTRUCTION
arbor,r provided for by Section 3700 of the IaMr Calc,for the fRdowantt of the
o
wrk rola permit is issued FIXTURES-PER TRAP
I haveaveand and will efic,on Worker'santeoftheCompensation Insurance,h required by Section.
37M offs labor Cale,for dm Performance oarm"o JfY--osrWWJJ^-w^�h+qicIh�su''yis,Permit is issued. GAS-G:SYSTEM-1 INC.40IITLEfS OCC.GNOUP AM
Cortievr �CE IFICA'F.OF EXEMPTION TR`OMWOR ERI(=I -1-I GAS-EA.SYSTEM-OVER 4(EA)
COMPENSATION INSURANCE - GREASERNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section oil but he completalifthe pewit is foronc hundreddollars(51000 GRF.ASETRAP
.r less.) � PLANCHECK PEE
I carify that in the performance ofthe work forwhich this permit is issued,l shall SEWER-SANITARY-STORM EA.200 IT.
not employ any person in any manner to m m become subject t.the Workers'Compcn- ENERGY FEE
ZZ. section Laws of California:Date WATER HEATER WNEWMLECfR
Q Anglican, "- ' - - GRADING FEE
y NOTICE TO APPLICANT:IL after making this Cenificme of Exemption,you should WATER SYSTEMITREATING
became subject o the Worker's Compensation provisions of the Labor Code,you most SOILS FEE
W
forthwith comply with such provisions or this permit shall be deemed revoked WATER SERVICE
Q PAID
CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PLMB. SQ.FT. Date Receipt z Ihcrtby affiwthat them isecomwmion leMing agency(pr the perfawance of P
W(:)
the work for which this permit is issued(See.3097,Cit C.) .,TOTAL:
O L^ Lenders Name
[U Landers Address TOTAL:
a I century that 1 have read this application mal state that the above information is BUILDING FEE
V) erect.l agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
U� building construction,mrd hereby authmice represeaoai .softhis city to enmrupon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE '
(We)agree to save,indemnify and keep hawlees at,City of Cupertino against ELECTRIC FEE
liabilitieajudgments,costs and expenses which may in any way.acme against said City ALTER OR ADD TO MI7CH,
in consequence of to granting of this pewit PLUMBING FEE
AP NT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000CFM)
MECHANICAL FEE
URCF R IOA1 NS. s ^ �`
AIR HANDLING UNIT(OVER IO,g10 CFM) CONSTRUCTIONTAX
Signatme.f ApplicanVConwctor Date EXHAUST HOOD(W/DUCE) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfature buildinSoccupant store or handle hazardous material HEATING UNIT(TO Igk000 BTU)
as defined by me Cupertino Municipal Code,Chapter 9.12,end the Healft and Safety
Code.Section 255320W HEATING UNIT(OVER 10110001 BTU)
❑Yes FIN. VENTILATION FAN(SINGLE RESID) PAID
Data Receipt#
Will the applicant or future building occupant use equipment or devices which
it hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP UHP OR 100,000 BTU)
itti ict? TOTAL 47 �W
,DYes 7 N - BOILER-COMP(OVER 100,000 BTU)
1 have read be hazmdous squ
materials timmenm under Chapter 6.95 of the Cali- AIR CONDITIONER
ISSUANCE DATE
forma Health&Safety Cade,Sections 25505.25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.pT.' -
building docs not currently have a tanset,that It is my responsibility to notify the occupant
of the pa,brmenls which must be met prior m issuance of a Cenificam or Occupancy. �a1�
Ownenuaathorized.gent _ Date TOTAL ISSUED BY: J �Lj..
OFFICE
MAY-13-1997 16:03 MINTON 408 741 1155 P.01i01
.6 ! J STANDARD NOTICE OF WORK COMPLETED AND NOT COMPLETED
"" 11 OTICE•An recomom
mendeliono may not have been eomoleted. ,8ee below,• ReemeMatbn,not Completed. This form Is prescribed
by the Stuolural Past Control Board,with whom a COPY must be filed by company within 8 working days after completion of work under
s contract.
THIS IS A NOTICE OF COMPLETION ONLY,NOT AN INSPECTION REPORT.
TT ZIP IMTYIDATI W Mitts
Cgmberl
10216 Ietes
eYxWerflincl 95014 47 06/21/1996
' THRA=I; TERmrm CONTROL NoAFFIX STAMP TO
805A Unleenily ATmtr BOARD COPY ONLY
LAS Cates,CA 95030
)r (4M 354.9944(408)395.7934 FAX
RgatsTRAT1oN 4 L310240
IMPORT 4 8271 STAMP 4 1291542U FSnOY a 709752
Notice e/ First American Title 12772 Saraton-SwOnyvale Rd. SarlitME, Ck 95070
emplatim Dawn 06 2 96
sant tot a1n P -Ma a Xem 12772 Sara a Road Sar&t= CA 95D70
06/21196
_ODntedoo tV Oh20173 Sara aQa-Ips Oates SaratMfli CA 95070
m
Property a .r: _Nr. 6 102
Mrs. J. GOrdCXf A168Y Lane O1Dartino Ck 95014
this Is to certffv that the foltming raseesttdetlerr an the above dnlBmted property, an outlined to weed Destroying Posta and
organfnn Inspection Seport No. 8271 , doted 04/26/1996 Weever we. 3116890T
Own been Wyer have not bean eonpleted.
beeenrdetimne completed by this fin that ere to accordance with the Wtntcturst Post Central Beard's Rules end loguloslom,
IteinS IA. 111. 1C, 2C 4A A tna were cOmole firm.
,e ndatiom coopketod by this flrw that are eenddered uceMery W eistWerd nsewros under section 1992 of the structure[
Past central Woerd's Rules and Regulations _None
Person r**Wotlno secondary sesourn
Cents W 1770.00
Inspection Fear 1 0.00
atheri s_ O.00
total 1 1770.00
lasewsnIltims not copleted by this flrA: Italia 2A. 2111 6 JOA,
lollaeted coat: s
Beserkst
t shank you. . .we de aoorecieta vour bus nasal
.t
neat•#i*aartattt-t#ia##tcart-#i*Creat#at#tiatra►tr#aa*taata►t#art#stet#tea}#
s to c a c be baron is now free of active
�f11 Vet.aL on or tow ,.a «t.0 visible and aso •`lei areae
i#r*t}ra*at#a#-#t*#-t###t*#t##*iia#}}*ia*#*a#inti##r}##########*t**#*#*tt#at
signature
NOTE!Questions or problem,eonearnlhnq the 4,4"feDen houid be dlrsaud to Iho men t of the aerrof y Onmolved cw tbn,or problems
with services performed may be enotsd to thVuetorM dot Control Boats N(1171#9 .7 or t If161 ee�•�7 N,er Ig I el 3EY1e71.
you we entitied to obtain 000los Of all n n,and completion net=en this Property nbd with ityA�.Beard during ted ooreeeedlno two ysw upon
payment of a 11.00 search los to: The tinctured hat COMM Ba ,1411 Nowa Ave.,Ste.2,Oaanl:wno.Centel 65415.7280.
M TOTAL P.01