S 1307 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI'fYsOF CUI'ER'I'INO RUILUING-ELECTRICA L Pitt
• Bus OFC PEIffIN APPLICATION/PERMIT PLUAf111NG-MECHANICAL J 1307
RUILDINO 11110.IECI'IDFNI'IF'ICATION
BUILDING ADDRESS: SANITARY NO. AVPI.ICAIR NSUBMITIALDATE
/097 &rA/Y'LOOOJ Av6 041Pr/27/,vo C'AJ-
VNER:S NAME. PHONE: CONTRACTOR'S NAME: LIC NO'.
NIC CONTROLX
NGV l n N/E7N [
RCtIITECI'/IiNGINEI3R; LIC NO: ADDRESS
: ❑
.1505" klfee .eO, SNAXIH LXINP+ (/. 5F6"Cs
CONTACE PHONE: - . BUILDING PERMITINFO
A
❑ Consultant Fecs Paid by Applicant(Initial) BI-P�G , ELECT PLUMB MECH
v'soi"Ve. IN.
Ej
LICENSED CONI RACTOES DECLARATIONQ'PY ELECTRIC PERMIT FEE
1 hcrcby afrnn don 1 tt
;on Ice ,ed mater pr—inion,of Chaptcr v Rommeacm, JOB DESCRIPTION
QaZwhys«tion'/IMq)afDivMinn3nnha nasi«s,ono Profesfiona eoee,and myeanwis RESIDENTIAL:
WOO PERMIT ISSUANCE
FW= in full force and ecce, / aG/$ 7G ❑SITWL 0 KITCHEN REMODEL
�UZU License Class Lic.tl Appi.IANCIiS—HESIDIeN 1'IAI. ❑ADDITION ❑PLUMBING RE PIPE
y<W Dae r % Cothran„r✓roe- MBsgL
AI<CIII'111CTS DECLARATION ❑MULTI-UNIT ❑STRl1CT,RAL
F O m PANEL S MODIFICATION
Z O in z 1 underslund Icy plats shut 1 he used ux puhlic ree.Ns
OZ 1—q UI'T020IA IPS []INTERIOR ❑CHIMNEY REPAIR
I,icen,cd Prol ...anal 201-1000AMPS IMPROVP,MP.N'1SWIMMING POOLS
F
OWNER-EUILIl1iR DI!CI.ARATIONOVER IINIl1AMl'S ❑EATII RI?MOUIiLBI?I'Alli ❑DE OIATION
C 1 hereby afEnn duct I am exaupt it Ilte Comma is Licevac Law Tim the
a OF Iollnwing rcrOm.(Seetioll 90315,Br inc,s and Profession,Code:Any city or county SIGNS EL,C'FBICAL ❑09'HER
shi'lfinc,rons a permit d t r alter.arprove.derrolish,or rmh-any aracmrc
.F.�O
prior to its'. also requiresthe applicant Fh Parinit to file a signed statement SPFCIALCIRCUI I/MISC.
cccc�y Nath Ic Jpms z d p ern- rdwC tvem 1' law(Chuptcr9
�dO (comment ng with ScUitz Thai)al'Dlv;sion Sof the Business and Pmm,xions Code)nr (RMB SIR I'ER OR F'OI.F NST. COMMERCIAL;
LMAha he is exempt therefrom and the basis Our the alleged excraption,Any violation of ❑NEW BLDG/ADDITION ❑DEMOIA TION
�- Section 9031.5 by anyapplicatn for a permit subjects the applicant to a civil penalty of POWER DEVICE ❑TENANT ❑FOOD SERVICE
Out mac than five hundred dollars($500).
FZY OT14ER IMPROVEMENT
G 01,os owner or the Property,or employees with wages as their soie compensation, SWIMM1IING I'( LELIiCTRIC
=C will do the work,and thcsaucture is not intended aroRerd mrsele(Sec.40,11.Business ❑OTHER
63m and Professions Calc:Thc Conlmctoi,Lice w,law data not apply to an owner of Of1T1.IGS- :WITCIII!S—FI%TIJRIS
property who miles or improves domain.and who Aces such work himself or through
his own employees,Provided that.such impmveearits are not intended or offered for NEW :SIDIiNTIAL EI.ECFR SQ
size.If,however.the building ar impnmement is sold within one yearofcompletlan.the WI SQ.Fr.R(X)H AREA 5/SQ.FT.
nerbuilder will have the huNeo oT proving that he did not build or improve for pro, 1.4
Ff
pose of sale.).
❑1,m'owner 0f We pmpeny,am exclusively contraning with licensed commnors to TOTAL:
consumer the projcat(Sec.7044.Bust...and Professions CIde:)The Comm I I Li-
nwlawdnesnotapply manownc,nf,mNny who build,or imprisons dhemon,and Y. PLUMBING PERMIT FEE
who contracts for such projects with a coommons)licensed pursuant h,the Coatmmor's
Limon taw. PERMIT ISSUANCE;
O l am exempt under Sec. ,B&PC forehis reason
I r Date
AIIFER—DRAIN&VENT—WR'I'ER IRA) VALl1AT1ON
WORKUR'S COM TENS At]ON DECLA RATION BAC K FLOW PRO I EC'K DEVICE / T
c I hcrchyalflnn under pcmiltyartperjury Ina of the f allowing declamtiars: - Q V
]Ihavennsl will maintain nCcnificumnl Cansennn xelf-insumfor Worker's Cnmpen- DRAINS—FLOOIt,R001',AIi11A,CONU' - 3001115 'TYPE CONSTRUCTION
satian,as provided I'oi by Semina 31110 of dirt,Litho,Cndq Gu the performance of the '
work for which lhi,pcnall is ixsued. FIXI'UItES—PIIIt'I'RAP'
0 1 hove and will nrcinmill Workm's Cour'lan radion Insurance,as m,aimd by Sermon
370DOrhe labor Cad a,for lire pedurrhnnme Of ha,is k fnr which th, rournit is issued. GAS—HA.SYSr1, 4 G'ULP'S OCC.GROUT' APN
My Wnrkcr's Camppclwntlon Iu,room corm,and Policy non he '
Canicc Policy Nn.: 5H 9D GAS—HA.S S” :1Y4H
C17KI'1171CNFII OF EXINF TION FROM WORKERS' G ' 'I: D .I'RI.WAST" NTIiRCEPIOR
Co MP17NSA'I'ION INSURANCE BLI_ILDING DIVISION Fii&S
eft
(Ihi"Ottion need not be mmpletedlfthe permit is l'mmne lmndred dollars($1 go + 51?'IRAI' ------
or Ica,.) PLANCHECK THE
I certify that in the peHonnanceofthewnrk for which this .it I,iamed.IahallSEWER—SANI'1'A —S'T[IRM EA.2W FT. p"
not employ any person in any mourner sur as to became subject to the Worker,'Compen- IrrvF F
� Z sation Laws of Califnmia.DateWATIiR IIEATP W/VE T/F.L1[CTR GRAVING FEE
Z Applicant '
NOTICE TO APPLICANT..If,after making this Cenificam of Exemption,you should WATERS rENAC REATINC.
F; becomam
e bject the W'orker's Compensation previsions of tire Ier Code,you must S
fonhwith comply withsuch provisions or this permit shall tie deemed revoked. WATE SHINICE /
7Z CONSTRUCTION LENDING AGENCY N RESIDENTIAL PLMH, SQ.EI. f P'X'IN sr Receipt
L)0 1 Immhy atfitm that Them is a con,lmm
etion lending agency for performance of
F the work for which this femur is issued(Sri,3097,Cir.C.)
I't• Lendnes Name TOTAL
V Lender.,Addms, TOTAL:
1 ecnify that I have read this application and ,are Nat the above information is BUILDING FEE
ii fA correm.l agree h,comply with all city and county.oinamesindsutelawsrelatingm QTY. MECHANICAL PERMIT FEE
CZ building consuuction,and hereby authorize repowmatives ofthis city mender upon the SEISMIC FRI:
above-mentioned property for inspection purll 111iRMI'T ISSUANCH
(We)agree m save,indemnity and keep harmless the City of Cupenina against ELECTRIC PER
Iiabilitiesjudgrnems.co.sis and expenses which may in any way acerae against said City AurIiRORADD'IUNI
sequence of the gruning of thin pencil, PLUMBING TEE
APPLICANT UNDERS'T'ANDS AND WILL COMPLY Willi ALL NONPOINTAIR HANDLING UNIT(1'()10,000 CFM)
SOURCE RECULA'1'IONS, NUCHANICAL FER
AIR HANDLING UNI'i(OVERFilms)CPM) CONS I'RUCIION TAS
Signature of ApplicrmdlCmnlmcmr - Dam EXHAUST l OOIOW/UIJCI HOUSING MITIGXHON FIFE
HAZARDOUS MATERIALS DISCLOSURE -
.Will the applicant or Immo huilding oo,d,xm,one nr bindle hnzarlor,ranterial HEM INC,UNIT'(I'D Igo,111N)B'T11)
as defined by the Capenino Municipal Cu In.Ch,a,,9.12,end the Health and Sufery
Code,Section 25532(x)7 HHAI INC,UNIT(OVER 100JUXI BTU
O Yes El NO VENTIIA'rION PAN(SINGLE .'ID) PAID Dam Rcccipta
Will the applicant ar future building occupant use equipment or devices which
emit harridan,aw,untamiwms as delineJ by the Bay Area Air Quality Management BOILER—C(1MP 0131' IIN),(MM)BTU7
TOTAL:
Dismit's BOILER—COMP ER I IT000 II'fU) .
❑Yea No
'
1 have real the ionization.mtmrials mryiremenu uMer Chapter/.95 of the Car- AIR CONDf )NEE ISSUANCE DATE
forma Health&Safety Cade,Sections 25505,25533 and 25534.1 understand that if the NEW .;I mNOTAI.1,11701. SQ.ET. '7 �Q
building dues nal currently have a tenant,that it is my resptm,ihiliry to nadfy the«cupam 2,1 !lIJJJ
of the require Is w ich ,t he met poor m kiremce of a Cenitiam of Occupancy.
d 2 96 9
rnnthodzwl agent Date TOTAL: ISSUED BY:
OFFICE
I
I
10300 Torre Avenue
Cupertino, CA 95014
Cit%, of
Cupertino Building Division
(408) 777-3333 (fax)
February 4, 1999
Homeowner
1097 Kentwood Av
Cupertino, CA 95014
SUBJECT: Permit 9S 1307
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, this permit has not been signed off by the Building
Department. Many times an inspector will sign the permit in the field, but overlook
reporting all of the information to the clerical staff for input into the computer. If this is
the situation and your permit card shows the final sign-off, would you please contact us
so we may complete our computer records? If the permit is not signed off, please call to
schedule an inspection for final closure of the permit.
Because of the large volume of paperwork within the building department, we cannot
separately monitor the progress of each permit. We ask that you-give this notification
your immediate attention. If we do not hear from you within ten (10) working days we
will remove the records from our computer.
Thank you for your assistance.
Sincerely,
CITY OF CUPERTINO
Christy Akatiff, Administrative Clerk
.v0
Printed on Recvclerl Paper _