29034APPLICANT TO FILL IN
'RED LINES - USE BALL POINT PEN ONLY
CITYOF CUPERTINO n.. BUILIDN"-CLCI:rtt16nL I -^ O^w
-APPLICATION/PERMIT PLUMBING.. MECHANICAL L 34
BUILDING DIVISION r rarer 1R111ReT mENTIRI..IION
-6011 7 it
1 h<"' "" Nal 1 am licensed under provisions of Chapter 9 (commencing
OZ with Sect ...7"Xpof Divisiun]ofthe Business and Pmfessions Coda and my license is
in full fmcurem ad.- a. /� 33 3
U. License CI u 3 Lie. is
Date.,�Cantm<mrLd O�\i
_., ARCHITECTS DECLARATION `codsrr
r�3s I understand my plans shall be usedas public recoks J
Z C
W Licensed Pmfessimed
` OWNER -BUILDER DECLARATION
g 1 herehy affirm dol 1 am exempt from the Contractor's License Low for the
Mfollowingnadem.(Section 7031.5, Business add Professions Code: Any city o....my
which mquirca a permit to craccomet, slur, improve, demolish, or repair any swnure
prio, 1. its ivande e, also requires the applicant for such permit to file. signed smmment
shot he is licensed pursmntm the pmeW.nsofthe Contrecmr's license Law (Chapmr9
p0(commencing with Senid..]000)of Division Sof the Bnearmssand Professions CWe) it,
e y that he is exempt therefrom and the basis for the alleged exemption. Any violation of
m oe Section ]031.5 by any applicant for. permit subjects the lipplicend 1.. civil penalty of
yp. not more t
will
ban Eve hundred dollars
tCy Q I] 1, as owner oldie propany, or my employees with wages as Ann sole compensation,
de Ne ars, athe twcture island intended oroffered for sole (Sec. 71144, Busincas
6 a and Purifications Calc: The Conuaaor s License Law docs not apply to an owner of
property who builds or improves thereon, and who does such wool himself or through
ee
his own employs, provided that such !trip ... Inums we not intended lar offered for
sale. If, however, the building or improvement is sold within one yearrif completion, the
owler-builder will have the burden of proving that he did nil build or improve for pur-
poserifaale.). -
❑ I. as oWar, of the prop[rty, am CACImOz[y contracting Wllh licensed cond ctom tri
construct the project (Sec. 7044, Business and Pmfessions Cade) The Comractura Li.
cense Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contmctorts) licensed pursuant to the Contractors
Licenu Law.
❑ 1 am exempt under Sec. , R & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the Ibllowing dedumtions:
t] I have and will maintain a Certificate of Consent losel&inaure for Workers Compete
tion, as provided fm by Section 37M of the Labor Code, for the Performance of the
wool for which this permit is issued
I have and will main t in Workers Compensation Insurance, as required by Section
37M of the labor Code, for the performance of Ne work for which this permit is issued.
❑ Consultant Foes Paid by Applicant (Initial)
tAPPLI�C�-RESIDENDDAL
ECTRIC PERMIT
PERMITNCE
LS
OVER 1000AM
SIGNS ELELTRICA -
SPF.CIALCIRCUI LSC.
'1'EMP.METER RPOLEINjiT
POWER DEVIC
SWIMMING POOL at
OUTLETS-SWITCHES-FIXTU -
NE IDENTIAL ELECTR FT.
QTY PLUNXING PERM IT
PERMIT ISSUANC
ALT 0.L
GRIN tVENT-WA R(SA)
(This section need not be completed if the permit is for one hundred dollars ($ 1 Bid
m I...)
I certify that in thc perfmmuace of the work for which this permit in issued, ) shall
not employ any person in any manner so as do become subject to the Worker[ Compen-
O Z sation Laws of California. Date
O Applicant
VVJJ NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you should
t '�^ become subject to the Workers Compensation provisions of the Lahr Code, you mnat
G foMwith comply with such provisions or this permit shall be deemed accused.
Q
CONSTRUCTION LENDING AGE NCY
V 0 .. work
which
nu that thenadi issued Nscti30 lending agency for performance of
E^ the work far which shin permit is issued (Sec. 3(197. CO. C.)
O V Lenders Name
L7a Lenders Address'
Dr
Lender';
a that I have rad II ciapplication and stale n. the shoal w. dl. ion is
N correct. l agree to comply with all city and county nWtives Of and amu lows relating to QTY
L) z bhavi-mach nalCom,and hereby authorizepurportunmtives of this city 10 enter upon the
above-mentioned to anysave for inspersion keep Co
(We) agree m save, indemnify and kith hay in an the City of rou unda against
liebilitiev,judgmente, costs and expenses which may in slay way .lemic against said City
r in consequence of the granting of this permit.
APPLICANT��tt11NDERSTANDS /fD WILL COMPLY WITH ALL NON -POINT
SOURCE R}/Qd(LATIONS. // I r
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stem or handle hazardous material
u del nW by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑Yes ❑No
Will due applicant or future building oecupant use equipment or devices which
mir h,zo O s air <onuurdnsntz m defnW by she Bay Arc. Art Quality Maaogemenl
riI?
❑Yes ❑No
I have read the hazardous materials departments under Chapter 6.95 of Ne Cali-
fomin Health & Safety Code, Sections, 25505, 25533 and 25534.1 undersand Nat if the
building deans not currently have a tenant that it is my responsibility to notify the occupant
of the re ulmments which must be met prior to issuance of a Cedificme of Occupancy.
Owner or authorized agent - Dale
DRAINS-'PLOZ/d: RSdF; XR@A, COND.
FIXTURES-PERTRAP
GAS -EA. SYSTEM -1 INC. 4 OUTLUS
GAS -EA. SYSTEM -OVER 4 (EA)
GREASF/INDUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER -SANITARY -STORM EA. 200 FT.
WATER HEATER WIVENTAILECIR
WATER SYSTEM)TREATING
WATER SERVICE
NEW RESIDENTIAL PLNUL SQ. Ff.
MECHANICAL PERMIT
PERMIT ISSUANCE - t
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10.1100 CFM)
AIR HANDLING UNIT (OVER 10,000 CPM)
EXHAUST HOOD (WMUCID
HEATING UNIT (TO 100.0)0 BTU)
HEATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER -COMP (3HP OR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU)
AIR CONDITIONER -
OFF
SQ. RT.
Ir L
IN
FEE
]OB ESCRIPTI
R SIDFNTIAL:
❑SFDWL ❑ KITCHEN REMODEL
❑ADDITION ❑ PLUMBING RE -PIPE
❑MULTI -UNIT [I STRUCTURAL
MODIFICATION
❑ INTERIOR ❑ CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEUREPAIR ❑ DEMOLITION
❑OTHER
-
OMMFR LAI;
C3 NEW BLDG/ADDITION ❑DEMOLITION
EITENAM' ❑ FOOD SERVICE
IMPROVEMENT
HER
NOV 15
ENERGY
SOILS
BUILDING FEE
FEE SEISMIC FEE
ELECTRICFEE
PLUMBING FEE
MECHANICAL F
HOUSING MITIGATION
Date
asis""
Receipt X
TOTAL:
January 15, 1996
Homeowner
11430 Charsan Lane
Cupertino, California 95014
SUBJECT Permit: #29034
Dear Homeowner:
10300 Torre Avenue
Cupertino, CA 95014
Building Division
(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
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