27791 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - - - PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 1
BUILDING PROJECT IDENTIFICATION
BUILDIN A&SS Q� A 2D. DNITN IOTN OR'S A N� NO. APPWGTION SUBM
OTALFATE
OWyyiRS)1W.f r_/�/{�y�P E CO LIC NO: !
ll//TT�u"-fiV� ✓✓-7N/C CONTROL"
kRC1517ECT/ENGINEER: LIC NO: ADDRESS: - ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT AEC' BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMITISSUANCE / �Ljf IK�f[—
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DESCRIPTION
IOc[z Ihereby affitmthat l ser licensed underprovisionsofatipter9(wmmencing wiN
c00ta�0I�. Section 7000)of Division 3 ofthe Business and Professions Code,and my time.is in PANELS
WdU full force and effect.
F ZFaI Licenu Class Lic.at UPTO2W AMPS
m 6 v Data Contractor 201-IOW AMPS FMV
ZF"z ARCHITECTS DECLARATION OVER IOW AMPS SQ.FT.ILtpRA BA $/SQ.FT.
AASP.-
Z ❑ I understand my plans shall he used as public records.
S t.- SIGNS ELECTRICAL 1 �
LicaLrod Professional
6 Q OWNER-BUILD ER DECLARATION SPECIAL CIRCUIT/MISC. O
tum
O a U Ihereby affirm nor ern exempt from the Contractors License Law for the
'3 tt tiG following reason.(Section 7031.5.Business and Professions Code:My city or worry TEMP.METER OR POLE INST.
which requires a permit to construct,dter,improve,demolish,m repair any svucher,
T� prior to its issuance,also requires the applicant fm suchpermit to file asigrod statement POWER DEVICES
OO that he is licensed pursuant to the proviiions of the Contractors License Low(Chapter
9(commencing with Section 0000)of Division 3 offle Business and Professions Cade) SWIMMING POOL ELECTRIC - VALUATION
^
_H arum he is exempt therefmmantl the basis for the dlegedexemptian.Any violuiw of Hpg-SWITCHES PICTURES
z Q Section 7031.5 by any applicant for a permit wbjects the applicant tae civil penJry of
!q G not mare than five hundred dollen($500).
p% ❑ I,asownerofthe ro NEW R IDENTIAL ELECT _SQ.FT. STORIES TYPE CONSTRUCT ION
p piny,ormotimanyeeswitheregesmtheirwle cam.Business will dothewon,aide:no are iersis License
aro dosed of apply in run
of
and Professions Code:The weadiccmr's Liaise Law does not apply lf rt owner is
properly who builds or improves thereon,end who docs such work hirstulf or dwugh his
own employees,providedNat such improvements eta not intendedoroffere-0fineele.If, o OCC.GROUP RES.UNITS
however.the building orimprovement is sold within one yearafcompletion,theownes-
builds will have the burden of proving that he did not build or improve for purpose of +
aal QTY. PL IN ERMIT FEE ELOOD LONE APN
1,a. wnerof the propeny.emexdusivdycontrurcmg with licensed convectorste
.const t the project ISm.7044,Business and Profeuioru Code:)The Cco m cons
License wdoes not apply to an ownerofpropeny,who builds or improvesthercan,and I PERMIT ISS CES
whoconwetsfor such Projects with a contrador(e)licensed pursuant mthe Convectors
License law. ALM-GRAIN& LNT-WATER(PA) FEE SUMMARY
❑ I em exempt under Sa. ,B @ P C fm thin aeon BAC W PRoDEVICB SANITARY TY DN
Owner Date 1o� RBCBIPI'M
wls
WORKMAN COMPENSATION DECLARATION DRAIN OOR,BOOP,AREA,COND. SCHOOL TAX Y N
❑ Ihereby affirm that l have a cenificam almoner to sel6insure.ora ceni0ceI of P P - s. RECEI
Workeri Compensation Insurance or a ceniftedcopy theardlSer.380),Lab C.)which sa` PARK FEE Y N
covers all employee's under this permit. GAS-EA.SYS C. IITLETS �• RF,CP p
Policyp BUIL N I SIGN FEES
Company GA1-CASY -O (EA PGNCHECK FFE
❑ Certified ropy is hereby famished. O
❑ CrniBW copy is filed wiN the city impwtian division. GRBASP/IND ST11 CEPTOR - GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE F�I
COMPENSATION INSURANCE
(This aminminecdmalor completed ifthe permit is far..hundred dollen($10)) SEWER-SANITARY-S RM WFT. ENERGY EEor lass.)Icenify Nat in the performance of Wework forwhichthisperritisissued,Ishall WATER HEATER W/VENT/ELEnot employ any person in any manner so as to become subject m the Workers PAID
zCompensationLowsofCalifomia. Date WATER SYSTEM?REATINGR
Applicant
C) 0 NOTICETOAPPLICANT:If,aBamaking this Cenifiateof Exemption,you should NEW RESIDENTIAL PLMR. SQ,FT. TOT
became subject to the Workers Comperuation Provisions of the Lobar Code,you must
LLYi forthwith comply with such provisions or this permit shell be deemed evoked. BUILDING FEE ,tea
1 Q CONSTRUCTION LENDING AGENCY SEISMIC F5,.JJCr `
Vz Ihereby affirm that there iso wmwdion leading agency for feeperformenw of ELECTR E r
O the work far which this permit is issued(SIL.3007,Civ.CJ
Lender's Name
�[�! Lender's Address - QTY. MECHANICAL PERMIT FEE PLU 'V
R
I certify that 1 have rid this application and state duet the above information is
coned. IagrsmcamplywithilleidysMcountyoNirunceesid sntehwerelatinIto PERMIT ISSUANCE MECHA CAL FE
�-' h building construction,aallourby enthrone representenvesofthisciryto enter upon the GON$TRGCTIO AX
U above-mentioned property for inspection puryoses. 1 ALTER OR ADD TO MECH.
(We)ague la save,indemnify und keep heirless due City of pareira against
liabilitiesjudgme muandexpenseswNch yinaay. arc againsbaid Ciry AIR HANDLING UNIT(TO 10,000CFM)
Ilse IPA
g fthi twit.
AIR HANDLING UNIT(OVER 10.000 CFM)
S gem Applcmt/Cantrac Ir to EXHAUST HOOD(W/DUCO PAID
HAZARDOUS MATERIALS DISCLOSURE.
HEATING UNIT(TO 100,00OBT Date R tN
Willtheapplicant or furore uuilding wcupant store orhwdle havrdoua material HEATING UNIT(OVER 100,000 BTU) AL:
es defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cede,Section 2 532(a)7 ENTILATION PAN(SINGLE RESID)
13Yes 11No
Willtheepplicanlorfumrebuilding mmrq
cupeuse uipmemordeviceswhichemit
OILER-COMP(3HP OR I X,000 BTU) ISS
unions air conuminants as defined by the Boy Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
mrt' ❑Yea 0 N 1995
NEW RESIDENTIAL MECH. SQ.FT.
1 have¢ad the hazardous materials requirements under Chapter 6.95 of the My tar ('UNtHIINC)
Califnmia Health&Safety Code,Sections 25505,25533 und 25534. 1 understand that
ifthe building dces not currently have a tenant.that it is my responsibility to notify the
occupsat of the requirements which most be met pnm to issuance of a Certificate of
Occupancy.
'JQOwne,mmahodredngem Date r,� ISSUED BY:
OFFICE
• 10300 Torte Avenue
Ci1:v t,f Cupertino,CA 95014
Cupertino Building Division
(408)777-3228
(408)777-3333 (fax)
:t March 24, 1997
Homeowner
10164 Carmen Road
Cupertino, CA 95014
SUBJECT Permit#27791
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 been finaled. Many times
an inspector will sign the permit in the field, but neglect to report all of the information to
the clerical staff for input into the computer. If your records show the subject permit as
finaled, would you please contact us so we may complete our records? If the permit is not
signed off your permit can be reactivated and an inspection could be scheduled for final
closure of the permit
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 in Perycled Paper