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29258
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO. BUILDING-ELECTRICAL PERMIT NO. �-� BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL BUILDING PROJECT IDENTIFICATION BUILDINGADDRES,S - SANITARY NO. APPLICATION SUBMITTAL DATE 7 S � .9nzt RLku l r 2six OWNN^R'S NAME: FHON& CONTRACTOR'S NAME: LIC NO: df NIC �O Lp ARCHITECT/ENGINEER; LIC NO: DH.55: ❑ CONTACT. PHONE: BUILDING PERMIT INFO ❑ Consultant Fees Pald.by Applicant(Initial) BL y ELECT PLUMB .CH LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE I hereby aroma that 1 ant Eemead mider provisions of Chapter 9(commencing - JOB DESCRIPTION "Z with Semion]Bg0)of Division3 of the 1lurincse soil Professions Cade,and mylicense is RESIDENTIAL: �U�F � iiceneClassnJ attest. PERMIT ISSUANCE ❑SFDWL HEN REMODEL License Class Lic.p APPLIANCES-RESIDENTIAL ❑ADDRION L BING RE-PIPE yG Dam Contractor Z�py ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT STRUCTURAL Z I understand my plana shall be oast as public records MODIFICATION pZ' UPT02W AMPS rr`a Y�I Licensed Prodcasiand TERIOR [I CHIMNEY REPAIR Sw•�J OWNER-BUILDER DECLARATION 2111-100 AMPS IMPROVEMENT G I hereby offirm that I am exempt from the Commamrs License Law for the OVER IOW AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION 30�U fallowing rcason(Sectiun 7031.3,Business vnd Professions Cale:Any city or county SIGNS ELECTRICAL ❑OTHER j� which sold.a Fish to construct,other.Improve,demolish,or repair any stmea re prim to its ismance.also requires the applicant forsucb Permit file usigned statement SPECIAI.CIRCUIT/MISC. W� that he is licensed pursuant 1.he providlo,ifthe Curia lx License Law(Chapter 9 gA rat (commencing with Section 7")of Division 3 of the Business and Professions Gde)or TEMP.METER OR POLE INSLCOMMERCIAL: Ill.q that he is exempt themfrom and the basis for the alleged exemption.Any violation of ❑NEW B /AUDITION '[I DEMOLITION iC 4. Section 70315 by any applicant for A Permit subjects the applicant to a civil Penalty of POWER DEVICES _ ANT ❑FOOD SERVICE C not marc Nan five hundred dollars(S5Wh IMPROVEMENT � � []1,as owner of the property.or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC yy will Bothe work,and the dramatic is not intended or offered forsale(See 7044,11usiness ❑OTHER 013 act and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES all I, rom 66 property who builds improver thereon,and who dues such work himself ur tro hugh his own employers,provided Nat such malum umme are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT. sale.If,however the building or improvement is sold within one yearofcompletion.the SQ.FT.FLOOR ARE_A��_!ll VSQ.FT. sr-builder will have the burden o(proving Nat he did not build or improve for par- ❑ 1,as owner oftheproperty,am exclusively contracting with licensed contractors to T construct d project(Sec.7BW,Business and Profession ds or i 9m Counselors Li cense Luwdroor suchapply nun ith aofpropcny who sedNmimtroves thereon,and QTY PLUMBING PERM IT FEE fA who mal.acm for projects withocomracmr(s)licenseJ pununmmthe Commctola License Lew. PERMIT ISSUANCE 'J ❑lam exempt underSer. ' ,B&PCfor this mason ' Owner DamALTER-DRAIN&VENT-WATER BEA) JAhV Irt,y, ' 7s:� ' WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE C11 10 I hereby aRarmiderpenalty ofsejo,one afthe following declarations: UrO© �Olhvve end will mvinmina Cenifimm of Consenun self-insure for Worker's Compcn. DRAINS-FLOOR.ROOF,AREA.COND, STORIES TYf`ECONSTRUCT[ON anon,as provided for by Section 370 of the Labor Co+l<.for the performance of the work far which Nis permit is issued it FIXTURES-I'F.R TRAP I ❑I have will will maintain Worker's Compensation Insurance,as required Is Satian 3700ofam labor Cede,for the pertormanceofthe work for whichthis permit is issued, GAS-EA.SYSTEM.I INC.4 OUTLETS t OCCGROUP APN My Workers Compensation Insurance carrier and Policy number am: Carries Policy No.: GAS-EA.SYSTEM OVER 4(EA) CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR BUILDING D ISION FRES 1Thieswtinn nerJnot becomplmed ifthcpermit is forme hundred dollars($I00) GREASETRAP or tern.) PLANCHECK FEE t Icenify that in the PerfnrmanccoRhe work fnrwhich this pertnitis issue J.I shall SEWER+SANITARY-STORM RA.200 PT. out employ any person in any manner ser ism become subject to the WorkersCompen- ENERGY FEE ration Laws of California.Dam WATER HEATER WNENT/ELECER zApplicant GRADING FR y NOTICE TO APPLICANT:If,after making this CeniOcme of Exemption,you should WATER SYSTEMGREATING I O become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE WW forthwith comply with such loommonsnr Nis permit shall be deemed revoked• WATER SERVICE fil Q CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FL PAID C) kforw ahthis that them isaconwdian lending agency for the performance of a¢ Rtt<iptg Le work for which this permit is issued(Sec.3097,Civ.CJ QLender's Name - TOTAL: {{{lSSS1111 Lender's Address 1 certify Net 1 have read this application wad state that the above information is BUILDING FEE Hcorrect.I agree m comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE U4 building construction,and hereby authorize rcpresentadvn alibis city to enter upon the SEISMIC FEE 00,LAD above-mentioned property for inspection pumice . PERMIT ISSUANCE (We)agree to save.indemnify and keep harmless she City of CoNi inn against ELECTRIC FEE liabilidcs,judgments,arse and expenses whichJI"in any way accrue against said City ALTER OR ADD TO MECH. PLUMBING FEE I.consequence of the granting clyhil Nmha;,�/ _T V� APPLICANT UNDER NT AND T ( PLY WITH AL1.NON-POINT AIR HANDLING UNIT 10,0011 CFM) SOURC'kBGU S MECHANICALE �9 AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRUCf1O TAX .t azure of Applicarmcis tac 4 Didea EXHAUST HOOD ORMUCg) HOUSING MITI ATIONFEE HAZARDOUS MATERIALS DISCLOSURE Will thcapplicanlafumrebuilding occupant morembandlehavudous material HEATING UNIT CFO 101000 BTU) as defined by the Cupertino Municipal Cole,Chapter 9.12,and Ne Dust and Safety Cale.Section 2.5532(a)? HEATING UNIT(OVER 10,000 BTU) ED Yes [3 No VENTILATION FAN(SINGLE RESID) PAID Will the applicant or future building of use c n t or devices which Date scapi q app gby the q Amen BOILER-COME(THE OR 10,110 BTU) -i. ihazWous an contaminants as definul by the Bay Arca Air Quality Management DistricC TAL: ❑Poe ❑No BOILER-COMP(OVER I00,000 BTU) I have read the humorous matenuls requirenuman under Chapter 6.95 of the Cull. AIRCONDITIONER .., ISSUANCE DATE Lamin Heahh&Safety Cale,Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT. building does not cumently have a tenant,that it is my responsibility to notify the occupant of the rryui caems which mum he met priorto issuance of v Certificate of Omupaacy. . Ownensr authorized a gent Dun- TTA ' ISSUED BY: OFFICE +®_ 10300 Torre Avenue • Cupertino, CA 95014 ('iiv ol, Gupertill0 Building Division (408)777-3228 (408)777-3333 (fax) January 15, 1996 ti4 Tenant 10297 S. De Anza Blvd Cupertino, California 95014 SUBJECT Permit: #29258 Dear Homeowner: 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 fmaled. 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 •