30404 APPLICANTTO FILL IN INFORMATION WITHIN HED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERM]'L'NO. 3 O �I OA
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BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. J (t
BUILDING PROJECT IDEAH IFIL'ATIUN
BUILDINGADDRESS: [TAR Y NO. APPLICATION SUBMITTAL DATE
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HI'T Cf/ENGINEER: LIC NU: A��)lY• C ❑
CONTACT. - PHONE: BUILDING PERMIT INFO
n e 7 i a a��[ ❑ Consultant Feu Paid by Applicant(Initial) BLDG E PLUMB MECH
kat 'c/Va1:31111
LICENSED CONT'RACTOR'S DECLARATION QTY. ELECT RIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
WOW0Z with Sard.7000)of Division 3ofthe Businessand Professi as Cade,andmy license is RESIDENTIAL
FOS in fu 11 fmce and eRa '•S.LI PERMIT ISSUANCE �F L
W .7..1-U ❑SFDWI, ❑KITCHEN REMODEL
<u s License `•• Lic.q
alde�9ar<__ Cantmctor_ APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
ARCHITECT'S DECLARATION PANELS ❑MUIXI-UNIT ❑STRUCTURAL
Z O,� 1 understand my plans shall lu used m public meurds - MODIFICATION
OZ—O UPT02MAMPS [I INTERIOR El CHIMNEY REPAIR
I-I2,F.; Licensed Rofessi...I 201-1(M)AMPS IMPROVEMENT
Y OWNER-BUILDER DECLARATION OVER 1100AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
C Q 1 hereby affirm that 1 am exempt from the Contractor's License Law for the as
OyUF
following Mason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL. ❑0'THER
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co,N which requires a permit to construct.alter,fmp ave,demolish,or minor any swcture
Og prior to its issuance,also requires the applicant four such permit to file a signcilmammem SPLCIALCIRCUIT/MISC.
;!IN that he is licensed pursuant o rise prevision of the Contractors License Law(Chapter Y
..OJ (commencing with Section 7")of Division 3 ofthe Business and l'mfessions Code)or TENIR METER OR POLL,INST. COMMERCIAL:
d a as thafhe is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
m Section 7031.5 by any applicant Tota permit subjects tehapplicant to a civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
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mu ro re Nan five hundred dollars(3500), IMPROVEMENT
6 p,J,as owner of Ne property,or employer with wages as their aide compensation, SWIMMING POOLE[ECTRIC
will do Ne work, it the swcture is not financed osurfaced fixe mle(Sea 7044,Business ❑OTHER —
abd Professions Code:The Convectors License Law does not apply to an owner of OUTLETS-SWTI'CHES-FIXTURES
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property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR SQ IT.
sale.If,however.Ne building or improvement is sold within one yew ofeompletion,the SQ FT.FLOOR'AREA VSQ.pT
owner-builder will have the burden of proving that be did not build or improve for par- y') ✓'+ ) -
pose of sale.). .
I,as owner of the properly,am exclusively contracting with licensed contractors to AVG 191996.
ansumpt the project(Sec.7044.Business and Professiuns Caret The Contractor's Li-
moeLawdoesnotapplymanownerofpmperywhobuildnorimprovesthereon,and QTY PLUMBING PERMIT FEE
who contracts for such p leets with a matractmis)licensed sonswntaa Ne Comrucmr's
License [,
Law. PERMIT ISSUANCISSUANCEx•T5� VUY Lf I IIItlV
E]I am exempt under Sec. ,B&P C for this reusun '1' Ur
^ Owner Date - ALTER-DRAIN&VENT-WAT LEA) VALUATION
WORKER'S COMPENSATION ULARATION BACK FLOW PR
ECOTECT.DEVICE.
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1 hereby itfirunder penalty of perjury one of the following aml...f ome
I have and will maintain a Certificate of Consent to self-insure for Worker's Compan- DRAINS-f0i RODE AREA,COND.
tion,as provided far by Section 3710 of the Introfonm
,Code.for the permea of the STORIES
TYPE CONS'1'I1UCI'ION
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,m moan rd by Senior
37M of the labor Care,for the perforomme ofthe work for which Nis perrrtt is ossa GAS-EA.SYSTEM-1 INC.4 OUTLETS OCCGROUP APN
My Workcr' Compc sutio mncyyccarier and Policy numbereJe: A//
Cartier. ((,q((Policy No.: 1 i TY' GAS-EA.SYSTEM OVER 4(EA)
CERTNI ATE OF F.MPGON FROM WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This union need not be completed ifthe permit is Income hundtMdo11ars(S100) GREASE TRAP
or less.) PLANCHECK FEE
Icmify that in the imformancenfthe work for which this pernm is canal.I shall SEWER-SANITARY-STT)NM EA.200 FT.
'not employ any person in any manner so m W become subjwt to the Workers'Compen- ENERGY FEE
2,Z sant.Lowe of California.Data WATER HEALER WNF.NT2LF.CTR
Applicant GRADING FEE
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMTREATING
ay became subject in the Worker's Compensation provisions of Ne Labor Care,you most SOILS IEE
W foMwiN comply with such provisions or this permit shall be deemedrevoked, WATER SERVICE
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Uz CONST RUC TION LENDING AGENCY NEW RMIDEMTAL PLMB. SQ.FI'. PAID
QQ I hereby effhrm chat iso construction 1,ndingagency for the performance. Dam eiplN
to the wick for which this pcmdt Is issued(See.3107.Civ.C.)
ttU'' Lender.Name TOTAL:
fY) LerdonsAddress TOTAL:
I cenify that 1 have read this application and smote that the move information is BUILDING FEE
f�A correct.l agree m comply with all city and county ordinances and shite laws relating to QTY MECHANICAL PERMIT FEE
UZ building construction,and hereby authorize repreunmtives of this city menta upon the SEISMIC FEE
above-memmoopi property for inspection purgese5. PERMIT ISSUANCE
(We)agree to save,indemnify and krep harmless Ne City of Cupertino against ELECTRIC I
Iiabilitics.judgments.costs and expenses which may in any way accrue against said City ALTER ORADDTO MUCH.
in consequence of the gmntingof this permit. - PLUMBING
FU of
APPLICANT UN , 'TANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0(0 CFM)
MECt{A uI IO T
AIR HANDLING UNIT(OVEN IU,(00 CpM) CONSTRUCf10NT X
Signature of ApplianVC sena Date EXHAUST GOOD(W/DUCT) HOUSING MITIG 'ION FEE
11 RDOUS MATERIALS DISCLOSURE
Wdl the applicant or future building occupant store or handle hazardous material HEATING UNIT CTO 100,000 BTU)
m dan al b me Cape room Municipal Cede,Chapter 9.12,and the Health and Safety
Code.: an 255321.)'1 HEATING UNIT LOVER 100,10(1 BTU)
09 1
Yes No PAID
VENTILATION PAN(SINGLERESID) Data Receipt N
WJI the pili nm or future building by the B use equipment rte Devices which BOILER-COMP(3HP OR 1(0.00111 BTU)
I
contaminants a defined by the Bay Arca Air Quality Management
strict. rr TOTAL:
Yu a FIN. BOILER-COMP(OVER IIXI,IXO BTU)
I have reed the herardoa tnamd.l,requirenam.under Chapter 6.95 of the Coli AIR CONDITIONER ISSUANCE DA
form.Health&Safety Code,Sections 25505,25533 and 25534.I und th
derstanat if the NEW RESIDENTIAL MECH. SQ.FT.
building Joel y veatenant.Nat it is my responsibility mnotify the rccupant
probe hich mt bnrfssm ofu Cenificuteof cupnncy.
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Owner nr uuthariudn m15m TOTAL ISSUED B .
OFFICE
0" cil,X
10300 Torre Avenue
1. Cupertino, CA 95014
Cupertino
(408)777-3228
(408) 777-3333 (fax)
'i
r April 3, 1997
j Owner d
Cupertino,
S.in De An95 Blvd.
• Cupertino, CA 95014
SUBJECT Permit#30404
Dear Business owner:: Z
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 permit card shows the final sign-off,
would you please contact us so we may complete our records? If the permit is not signed
off, 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 erk
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