27875$LICANT TO FILL IN INFORMATION WITHIN RED LIP
OF CUPENO
BU APPLICATION/PERMIT
BUILDING DIVISION
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that Ism licensed under previsions of Chapter9 (commencing with
Section ]000) of Division 3 of the Business and Professions Cade. and my license is in
full force and effect.
License Class Llo.k
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records.
Lmensed Rofesstonal
OWNER -BUILDER DECLARATION
I hereby affirm that 1 sec exempt from the Contractees License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requir a permit to comma, alma improve, demolish, or repair any snetnre
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the Provisions of the Contractor's License Law (Chapter
9 (commencing with Section 0000) of Division 3 ofthe Business and Professions Code)
or that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
❑ I, as owner ofthe property, or my employees with wages as theirsole compensation,
will do the work, and the structure is not intended or offered far sale (Sec.]044; Business
and Professions Cale: The Contractor's License Law does not apply to an owner of
Property who builds arimproves thereon, end who does such work howelfor through his
own employees,provided thatsuchimprovemenrsvenotimm�dedorofferedforsole. If,
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ 1, as owner of the property, saw "elusively contracting with licensed contrectom to
construct the project (Sec, 71ap4, Business and Praf sioos CWa) The Contractor's
License Lewdoes not applyct an owaer mprupeny who s dIdsroimproves tberecn, end
Lho icense Law, Fm such projects with ecommeror(e)' pursuentmthe Contractees
License Law.
❑ 1 am exempt under Sec. , B & P C for this reason
❑ IhereM1y affirm thayyJJ�eecenifimte of consentm se Ginsure, orecertificate of
Wnrkers'Compe MI�Insurance arecertiFlW copy thereof Sec. 3800, Lab C.) which
ersall oyee's ander Nis permit.
Policy N
Camp
J
❑ C Ified copy is hereby Tum�h t a
❑ C Nfiad copy is filen wish th{cif 1pection division.
tin no comptetedilthe pe 4Llsfmapehuadredddhes($IW)
Icert y bei i- a otmance ofthe rk for which Nie petmi[is issuW,lahall
not ample Pe 'any reamer .,o as to become subject or the Warren'
so Compensati Laws. ifomie. D e
OIZ Applicant
NOTICE TO PPLICANT:ILaf r making this Certificate of Exemption, you should
.`+ become subi-toshe Worker' ompensamad provisions ofthe Labor Code, you must
�i , forthwith comp wiN such visions or this pemdt shall be deemed revoked.
G C STRUCf10N LENDING AGENCY
z I hereby afE t there is a c-solomtion leading agency for the perfamumce of
U O the work for which is latudd is issued (Sec. 301D, Civ. C.)
IY Lender's Name
O V Lender's Address
1 cenify that 1 have read this application and state that the above information is
correct. l agree to comply with all city and county ordinances andsone laws relating to
(�S huildi ng construction, and hereby authorize mproodurolves of this city to eumr upon the
U FFGy77 above-mentioned property for inspection purposes.
(We) agree to sure, indemnify and keep harmless me City of Cupertino against
liabilities,judgments, costs and expenses which may in any way accrue against said City
mau
eoaseeit—ftbeomnn-edf.:aw....b — a a _
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or form building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)1
❑ Yes Cl No
Will the applicant or future building occupant use equipment ordevices which emit
mMoris air comaminams as defined by the Bay Area Air Quality Management
himet?
❑ Yee ❑ No
1 have mad the hazardous materials nexprimmeno, under Chapter 6.95 of the
California Health & Safety Code. Sections 25505, 25533 and 25534. 1 understand that
if the building does not currently have a tenant, that it is my responsibility to notify the
occupant of the requirements which must be met prior to issuance of a Certificate of
Occupancy.
Owner oramhonz,. 'em One
BALL POINT PI
BUBEIPG
PLUMBING
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
IIP TO 200 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUTTMISC.
MP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIALELECTR _
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & VENT - WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF, AREA, COND.
'FIXTURES - PER TRAP
OAS -EA. SYSTEM -1 INC.4 OUTLETS
GAS - EA, SYSTEM -OVER 4 (EA)
GREASWINDUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER - SANITARY - STORM EA. 200Pf.
WATER HEATER W/VENT/ELECTR
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMIL SQ. IT
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10," CPM)
AIR HANDLING UNIT (OVER IQII00 CPM)
EXHAUST HOOD(W/DUCT)
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 100,00) BTU)
VENTILATION PAN (SINGLE RESID) '
BOILER - COMP (3HP OR 100j)D0 BTU)
BOILER - COMP (OVER 100,(00 BTU)
NEW RESIDENTIAL MECH.
PLANCHECK USE my
GRADING FEE
SOILS FEE
ENERGY
PAID
Receipt q
SEISMIC FEE
ELECIRICFEE
FEE I PLUMBINGFEE
CONSTRUCTION TAX I
PAID
Date
PAID
MAR 30 19air
CII Y Ur t ,
a.. ISSUED BYYNIi
27875
`
SANITARYNO.
APPLICATIONSUBMITTALDATE
3n S
N/C
El
CONTROLN
FEE
IT INFO
BLMB - ME
ION$/SQ.
rG
FT.
VALUATION
STOQIES
C. GROUP
FLOOD ZONE
TYPECONSTRUCTION
RES. UNITS
APN
FEE
FEE SUMMARY
PLANCHECK USE my
GRADING FEE
SOILS FEE
ENERGY
PAID
Receipt q
SEISMIC FEE
ELECIRICFEE
FEE I PLUMBINGFEE
CONSTRUCTION TAX I
PAID
Date
PAID
MAR 30 19air
CII Y Ur t ,
a.. ISSUED BYYNIi
November 12, 1996
Homeowner
10521 Castine
Cupertino, California 95014
SUBJECT Chimney repair: Permit #29325
Dear Homeowner:
10300 Torre Avenue
Cupertino, CA 95014
Building Division
77-322
(408) 777-3333 (fax)
We have been cleaning out our files in the Building Department, and contacting those
people with permits which have remained "open".
According to our inspection records, the subject permit has never 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
=f� 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
Pm,red 011 Recycled Paper
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ADDITIONAL PERMIT FEES 1�� V`^-
BUILDINGPROJECT IDENTIFICATION
VALUATION
MINE
OF owNLBs
NAME
UAtiI PHONE 33-31a
FEE SUMMARY
NAM Ac*aps _
CJfL.7l LIE. No
BUILDING
PLAN CHECK
FEE
nooniis Tops _
PHONE
SEISMIC FEE
DTY. ELECTRIC PERMIT FEE
UTLETS- SWITCHES -RECEP
ELECTRIC
LIGHTING FIXTURES
pLUMBIN
pPLIANCES- RESIDENTIAL
PANELS
MECHANICAL
SIGNS
TOTAL
SIGNS TRANS.
SPECIAL CIRCUIT
EMP. METER OR PO INS.
PERMIT VALIDATION
ISSUANCE DATE.
MOTORS SEE FEE SCH.
SERVICE CHAN
LZ
Ld OTAL
PLUMBING PERMI FEE
DNi�f
eLoc.
❑
ELECT.
❑
rLc.
MEC..
❑
ALTER -DRAIN &VEN RI A
BACK FLOW PROTECT, I
1 _ `
IrCG/I C—T/]
wk,F-v
iJ�. _�)�.
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C
PA0®
OCT�
CT 19 1995
T�,.
'r Vr 1/UI�CfI I�j�f
ROOF, AREA,
DRAUYFIXTURES-
IXTU ES -PR,
F I%TUR ES -PER TRAP
GAS-EA.SYSTEM-11NC.4OUTLETS
GAS IEA.)
INDUSTRIAL WASTE INTER.
STR ALWAS E INTER
LAWN SPRINKLERS - 1 INC 5 V.B.
LAWNSPRINK-SANITLERS-ORM
SEWER -SANITARY -STORM EA. 200h/
EA. 20
WATER HEATER W/VENT
WATER SYSTEM
WATER TREATING EQUIP.
TOTAI
OTY. MECHANICAL PERMIT FEE
ALTER OR ADD TO MECH.
APPLIANCE
_
AIR HANDLING UNIT ITO 10=CF.M.)
AIR HANDLING UNIT (OVER 1Op00CEMI
EXHAUST HOOD (WITH DUCT)
HEATING UNIT (TO 100,000 B.T.U.)
HEATING UNIT (OVER 100,000 B.T.U.)
VENTILATION FAN (SINGLE)
BOILER - COMP (3 H.P. or 100,000 B.T,U.1
BOILER -COMP (Owr 100.000 BTU) SEE PEE SCH.
_. TOTAL