30144 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL 3014
BUILDING PROJECT IDF,NMFICATION
DUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA'II
aly9U CAL 04 C+
OWNERS NAME: PHONE: CDNTRACTDR INAMG LIC NO:
<H2
¢ RN 9[ BZSL NIC CONTROLf
�RCHITF:CTk1 fHE1 R: LIC NO: ADDRFS.: ❑
CONTACT: PHONE BUILDING PERMIT INFO
❑ Consultant Fete Paid by Applicant(Initial) BL PLumB MECO
LICENSED CONTRACTORS DECLARATIONQTY ELECTRIC PERMIT FEE ❑ ❑
I hereby afrinn that I am licensed milru ama
miler pvisiwof Chalker 9lcncing JOB DESCRIPTION
wo, with Seed.7")of Divuim 3ofde Husireas and ProfnsioesCode.and any Hassesc is RESIDENTIAL:
1- in full face endeffect. PERMIT ISSUANCE
Q CUU Liarue Clea Lic.l ❑SFDWL ❑KITCFiFN REMODEL
QL Dan C..,., APPLIANCES-RFSTDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O,'2 e, 5 I undMi
casurd my,Ions all be."a,pth is reco o. MODIFICATION
OZ'LZ UPTO 200AMP$ ❑INTERIOR ❑CHIMNEY REPAIR
1-4-1..y..II Lacerated nonseasonal 2U1-1001AMPS IMPROVEMENT
Q I thereby efrirm Nat NTwn a new,afrml he Cd�ntruOa'a License Lew for the OVER 1000AMIS ❑BATH REMO F. DG ITION
x36U fcZoaingrenwt.(Section 70315.Busitms sed Pfofaa4om Cade:Any city or comely SIGN'S ELECTRICAL 0OTHFA
41 u. which rryuires a permit to ronenti alter,impmve,dcmuli h.or o,s it any situation,
E' Priamini.arat'alon"airesde,"icant fursuch,anir m file•signn
ed Mocont SPECIAL CIRCUFUMISC.
�} thin he is liceroacur
dlsupo
ant to the visimu ofthe Contrmr
ecs Lis Low(Chapter9
{Yp0 (comrrcncing with Section 14100)of Diaision 3 of the BiunosW Rofcsions Code)or TEMP METER OR POLE INS?. COMMERCIAL
Q. e that he it cwmlk thcrcfr.t ual tM haats for tM1c e11egN a¢mptiun.Any viuluti.nr ❑NEW BLDGJADDITION ❑DEMOLITION
Smi.]UJIS by any applicemfmepemdt whjects Jr epplieeet tuedvil,emhy of POWER DEVICES
..y that mate than rive huMana dollars lg5rot. ❑TENANT ❑FOODSERVICE:
�"Z'6 ❑ Le:owrcroflM prpmy,arm tm,lo an wish wogu utMir hale uxnIMPROVEMENT
y y pnwtim, SWIMMING POLL ELECTRIC
€� will othewort.Codec he Creniefors eMN.o,doesnor.'I''.nsoo nerds ❑OTHIIi
W aril erry who
Cao:The C.t torreor,U.Lew Jas not xIyly to an owner of OfII1PIi-SWRCHES-FIXTURES
d 3- tm�y hand oye,i.aha impdvth thNich i and who don wan wart intended
or nr Nrugh
his own an,,o.she provided that.wch impavencnts ere not i cad s or ardml for NEW RP_SIDENI'IAI.FI,F,CTR SQ FT.
auw,-loriler will
otinathegmenof,rmcnti(hailwithindrcycuafmm,le for tate 'SQ.FT.FLOOR AREA SSQ.FT.
amer-ballJer will hove the Meda of paving tint he did ma build aimprove fm,ur-
rj
i ❑I.as owns,ar Be ptwear,am aaldaivay axluxOng with Lianud aontreataa in
caouact the prjcct(Sec.YIN],Bu a.and Professions Code:)The Consacmrs U. Q 02 19
cense law Jaen not apply no an owner of PoI who builds or im,mvo thermn.and TY. PLUMBING PERMIT FEE 4]96
whoa trm fareachprujecuwiNacmtmeor(s)lice ,awaittdO C.twa s
Law.
under Sac. ,B&1'C for this reason PERMIT ISSUANCE �I�Vr (.UF'tr 11 u
Owa.. ALTER-DRAIN&VENTWATVR/6�_C
IfVALUATION
WORKER:S COMPI..SATION DECLARATIONHACKFLOWPROTECf DF 1 r
I hcrchy aRrt unor penalty nf,crjury an n[the following deelvntions:
�]Ihavc read wJl mainuine Ccrtiftcatc afC.rent to self-iwve fm W'atcr:Canryrn- DRAINS-FLOOR,ROOF.AlkiZA.IXS STORIES TYPE CONSTRUCTION
aati.,as noicles]for by Secti.3](10 of the Ichor Calc,for Be,crf.e of the
hawk fac which this,cono is lamed. FIXTURES-PER'IRAP
❑ 1 hive and will mwntein Workers Cvmpenwtidn Immwce,a,rt90iml by Section
3700ofdc labor Cude.fordreptfamvmeoflhewark fmwhich Baia permit isiaii GAS-G.SYSTEM
OCC GROUP APN
My Workcr'a Com,cmati.Iruurucc cannerrind onumahem:
Cerra,.Cerra,. Policyy NNn:: GAS-FA.SYSTIJN�OV ER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASPANDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
'Bi,salon ceN not he aorpktN ifthe pnnit is ran mehirwad
dllaa(5100) GREASETRAP
hal ss)
IcmifY she in Be perfomumz of Oe caret fawhich this pnmit isiuuN,lilWl PLANCHECK FEE
aR cmpiny any pcson in anymermcr w m to hcOoc sub*l to the Watcri Com SEWER-SANITARY-STORM W.2(u FT.
Z it.ls..fCu1lfarom Date ,ctr ENERGY PI:B
O WATER HEATER WIVEM/FLECTR
Z O ICnn GRADING FEE
NOT
rte-. NOTICE'.APPLICANT. e,reit.making Dia wmon, f,h F tntlkion,yna alcold WATER SYSTFJr1/IRFATING
hecomc wompm it Woch Msisi.or
crain,oati of the WNv Cods,you mu4 SOILS FEF,
� r
forthwith comply wNattch,mvtsionarcdtis Taman stall he Jeennl revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY
cai,y NEW RESIDENTIAL PfA1B. SOFT. PAID
UQ IhertbyefBrmthc dertisases]( ce.30ending
s.egaeyfa meper(ortwx of Dare Recciq♦
� F Be wmt rm which mire,remit is[a,eee(Sac.309].civ-.c.)
0U Lmdcrs Namc 'TOTAL
herder'M AdJresa - T(ITAL:
pW, 1 amity that I love reed IM1u aPfRiaetim hal Minta that dre¢hoax itJ«Teti.is BUILDING FEE
(A concea I agree to connEy wilh all city and aunty aninemee and vee laws relating to QTY. MECHANICAL PERMIT FEE
U Z M1uilJing cunurction,wJlmrcny au0lonzc rtµ.nntivcs ofWis citymrncr u,an the SEISMIC REE
r above-rtlent:aocd pRe*tY fa impecti.ptryoua. PERMIT ISSUANCE
(We)elate to save,incemnify and keep Mrmks ft City of Cdpeni.oleins, ELECTRIC FEE
Iiabihtio,pd,—u,costs had exper,ca wh ch moy'm any wxy accrue egzhw wid City -
n curryuenc,or me groom,of thio permit. ALTER OR ADD TO MECH. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT QO IU,000 CFM)
SOURCE REGULATIONS. I MFCHANICALFEE
AIR HANDLING UNIT(OVER 10.001 CFM) CONSTRUCTION TAX
Sigrouvc MApplinnVC.tranm Ih¢ EXHAUST FOOD(WMUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the epplieent or future building oca{ud uac or haeme hazudonta nwevial HEATING UNIT(M I PO.UoO BN)
as defird by the Culertim Municipal Code.Clasper 9112 and the Ilaldl aril Safny
Cock,Section 25532(u)'f HEATING UNIT(OVER 100,010 BTU)
❑Yea No PAID
VENTILATION FAN(SINGLE RESID) Ihtc ftcccipe
Will IR`rl ,licnnt fulurt huilding.cu,mt dm tyuipmcnt ox Jeviccs which tlOILER-COMP(JILT OR 100,000 HTO)
t hiscai ur urnmmns
itam defrnl by the Bay Ara Air Quality Monagemcm
Dina, 0
BOILER-COME(OVER 1004 BTU) TOTAL:
❑1'a No
I have read die hizwdotu mveriala AIR CONDTTIONER ISSUANCE DATE
re'25533 n tick Caulker rsta of to Cali-
fornia Health&Safcty try have
Sections thus i,ix cy had 255]4.T to resuM Ow if the NFIV RESIDENTIAL MECH. sQ.FT
writhing dca nor r a which hsi lie rnant,that n ie my reynmibilily to ntlify dre rccuptlm
olthe«quirrncma which owsromn pia m-....vac oro Cmtiflaa of Orcupemy.
Owner or eullKKlzcd agent Dale TOTAL: ISSUED BY:
OFFICE
01- Ch
10300 Torre Avenue
t 1, Cupertino,CA 95014
Cupertino Building Division
(408)777-3228
(408)777-3333 (fax)
March 24, 1997
i
Homeowner
21890 Dos Palos Court
Cupertino, CA 95014
SUBJECT Permit#30144
Dear Homeowner:
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
l�
Printed an Recycled Paper