30179APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
PERMIT NO.
30179
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMIPI'AI, DATE
CWNE r NAA ? / PHONE:
iel vIC
CON'!gq OR'S NAME: LIC NO:
N/C
❑
CONTROLc
�'4RCIII
TEC'I'/IiN01NEliR: LIC N0'.
AI RESS: Ii e
CONTACT: PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (initial)
BLDG EL CC PLUMB MECH
El
ElutImm
LICENSED CON I'RACIOR:S DECLARA'I ION
1 hereby affirm thm 1 am licensed under poof Chapter 9 (commencing
with Section 701M)ofDivi.sion J ofthe Busmos and Profmsions GWe. and my license is
in full forte effm. Lice
Liccnu class
Dec Contactor
QTY. ELECTRIC PERMIT FEE
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DESCRIPTION
RESIDENTIAL
❑$FOWL C) KITCHEN REMODEL
❑ADDITION El PLUMBING PLUMBING REd'
❑MULTI-UNIT. ❑SrTRUCTURAL
MODIFICATION
[I INTERIOR Cl CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMOUjL IR )IiMOLITION
❑OTHER Lt7e-}hja
PERMIT ISSUANCE
APPLIANCES- RESIDENTIAL
NICHII ECT'S DECLARATION
I understand my plans shall be used m public records
PANELS-
UP'IY)2IX)AMPS
Licensed Professional
OWNER-BUILDER DECLARATION
Bm
I hereby vrthat I ern exempt from the Contractor's License Law for the
following rcvaun. (Section 911.31.5, Business and Professions Cade: Any city nr county
201-I00IIAMPS
OVER IMO AMPS
SIGNS ELECTRICAL
LL LL H
Q
y
ICOO
• 60
w
iSG❑Lothe
F
63 m
which tetluires a permit In cmntrarl, altar, improve, demolish or repair any structure
prior to is issuance. also requires the applicantfor such permit to file a signed sumrncm
That he is licensed purevanuo the provisions ofthe Contractor's License Law (Chapter 9
(commencing with Section TKIO)o'Division Jofthe Businns and Posksnion:C:dc)or
that he is exempt therefrom and the basis for the alleged exemption, Any violation of
Section 71315 by any applicant lira pemul subjects 0e appl,iim lou civil penullY of
of more thanv%owne live hundred
perty r yempl
work. theprosamenurmyemplendes woffereforodewages as (Sec.c .Business
will dothssionsCde: The toreatolsLicenseed La offered ntapplyto an,Business
and Profcuiom Code: TTe Commclors License Ww' des urn apply to an owner nl
property, who builds or improves thereon, and who does such work himself or through
own employees, provided that such Impnrvenems we out intended Or offered for
SPECIAL CIRCUIT/MISC.
NX
TEMP. METER OR POLE
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
[_1 TENANT ❑FOODSERVICE
IMPROVEMENT
❑OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES-FIXTURPS
fk
NEW RESIDENTIAL ELECTR SQ FT
Iti 's'his
sale If, how use, the building"I improvenem is sold wilhi n one year of anmplelks, the
SQ OUR OUR AREA
oN
S/SQ. FT.
owner-builder will have the hurden of proving Nut he did not build or improve for par-
V
pose ofxale.).
El ElI, sa owner of the property, am exclusively contracting with licensed contractors to
19
9%�s
TOTAL:
construct the pnriect (Sec. 7044. Bminess and Profexsinnx Cade) The ConmacudU.
Uh a/
cerse Law does not apply manowner ofpntpcnywho builds orintprovesthereon, and
QTY. PLUMBING PERMIT FEE
��rr
who contmcls for such projcdn with n conovanr(sl littnmJ punuunun the Commco-da
/(nU
\ PERMIT ISSUANCE.
License Low'
❑Ia underS ,B& P C for this reason
ALTER - DRAIN & VENT- WATER EIA)
a
Owne Date
�Qt n "VALUATION
b
WORKER'S COMPENSATION DECLARATION'
BACK FLOW PROTECT. DEVICE
+t'
1 hereby infirm under feralty of perjury one of the following declarations:
(have vnJ will mainminx@nilicam of Cnnscnun self inwre fist Workch Co..pKr-
mlion, as provided for by Section J]Il0 of the Lahrz Code. for the performance of the
J I,F r
DRAINS- FLOOR, ROOP,AREA. GOND.
V(`STORI 5 ��
'TYPE. CONSTRUCTION
FIXTURES -PERTRAP (II
wa k for which Ibis perem, is ixmed.
j 9/k
❑ 1 have and will maintain Worker's Compen.mtion Insurance, as reNumcd by Section
r / �h, r v
J]Oooflhe Lbor Cade. for the prdentanceofshe work forwbich this permit is issued.
My Worker's Compenamion Insurance currier and Policy"umbar ate:
GAS -EA. SYSTEM-]INC. 4 OUTLETS /��
OCCOROUP
- J/NU
APN
Cartier: Policy No.:
GAS- EA. SYSTEM -OVER 4(EA)
CERTIFICAI E 017 EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed ifthe permit is forone hundred dollars (SIM)
or less)
GRFASFJINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
GREASE TRAY
PLANCHECK HE
SEWER-SANITARY-STORM EA. 200 PC
,.
,�
z O
Icenify that in the perfomrvnce of the work lir which this permit is issued, l shall
Mat cntploy any person in any rwnner so as to hecotic wbjecl Io the Workers' Conipen-
Blinn Liov,of Culifnmiv. Dmc
Applicant
ENERGY FEE
WATER HEATER WNENT/ELECI'R
GRADING FEE
NOTICE TO APPLICANT: If, after making this Certificate of 17 costume. you should
became suhjen m Or Worker's Comprnsmion previsions of the labor Cade, you must
forthwith comply with such provisions or this permit shall he domed resulted.
WATER SYSTEM?RIiAI'ING
rn
Lit
SOILS FEE
WATER SERVICE
Q
�2
U�
CONSTRUCTION LENDINGAGENCY
I herebywhich int at permit i is vured(ructio97.Ging agency for the Performance of
the work for which this permit is isaucd (5¢. J09], Civ. C.)
PAID
Dam 1,
NEW RESIDENTIAL PLMB. SQ. FT
AA TOTAL:
0 U
} 0
F Tan
Lender's Name
Lender's Address
I tinily thin 1 have read this application end clam that the nbave infornrulio i ie
rntrea.l agmcmmmply wilb all city and county oNinances and sem lava rclmirtg rn
building coninueion, and hereby authurite representatives ofthis eitYmcner upmlhe
BUILDING FEAA
SEISMIC
QTY. MECHANICAL PERMIT FEE
above-mentioned prespeny for indpction ptapp ses'
(We) agree to eve, indemnify and keep harmless the City of Cuprtimo against
PERMIT ISSUANCE
ELECTRI .
liabililies,judgmems, coals and expenses which may many way accrue against said City
to nac,enee of the granting of this penal
ALTER OR ADD TO NIECE.
PLUMBING FE Cat
AIR HANDLING UNI '1'(TO 10.0MMI CFM]
MECHANICAL FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT'
SOURCE REGULATIONS.
AIR HANDLING UNIT (OVER 10.001 GPM)
CONSTRUCrIONTAX
d
Signvtumnf ApplicandConttacmr Date
HAZARDOUS MAIERIAIS DISCLOSURE
EXHAUST HOOD (W/DUCT)
HOUSING MITIGATION FE
I IIIAHNG UNITC 1) R 0,000 BTU)
Will the applicant ser lidme building occupant store or Wmdic baeamous material
as defined by the Cupenino Municipal Ctde, Chapter 9. 12. anti the Health and Safely
Code. Section 25532m)?
HLiADNG UNIT (OVER 100.000 BTU)
❑Yes ON.
Will thea licam or future building McexwWrb
' PO g o¢he Bay use Air
mit h:taardoux air nnnarninums as JcfincA by the NnY Arca Air Quality Munngcmm�t
DistrinP
PAID
Dam Receipt M
VENTILATION FAN (SINGLE RF_SID)
BOILIIR-COMPOHPOR fgosmuTU)
1111A1.:
❑Yes ❑No
BOILER -COMP (OVER 100,000 BTU)
AIR CONDITIONER
I have read th<hvaNaan macrials is under Chapler 6.95 of the Cali-
rc.
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. FT.
forma Healthgdoes & Safety Coale, Sections Irma 25505, is my end 255]4.1 unnotify W ma if the
2553 a
tomo is my rat salify Iheauaray. n
building dawn not currentlyh have u tenet
ce of axibilhy
of the requiements which must ll) met priormi,acnunac ofu Certificate oR)uvpaney.
p
ISSUED BY:
Owner ser auNomW anor Dam
TOTAL:
OFFICE
•
Of
Cuperthlo
March 24, 1997
v
Homeowner
21384 Dexter Drive
Cupertino, CA 95014
SUBJECT Permit #30179
Dear Homeowner:
10300 Torre Avenue
Cupertino, CA 95014
Building Division
(408)777-3228
(408)777-3333 (fax)
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 on Pecvcled Paper