S 0788 A..PPII-CANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL PFTIT NO. 0788/1/N
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. J VX8
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
'S NA E: �� tVONE: CONTRACTOR'S NAME: LIC NO:
Y NIC CONTROL#
'ARCH E NGINEER: NO: ADDRESS: ❑
CONTACT'. PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB ME
❑ ED ❑ .
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby amrm that I am licensed Bd order adP mens of chapter 9(commencing 706 DESCRIPTION '
��Z with Smtion]000)of Division3nf the eusineas and Professions Code,and my license is
F O in full have and effect. - PERMIT ISSUANCE RESIDENTIAL:
U U License Class Lir.a - ❑SFDWI. ❑KITCHEN REMODEL
hZW Date Contract, APPLIANCES-RESIDENTIAL ❑ADDITION - [I PLUMBING RE-PIPE
>> ARCHITECT'S DECLARA'T10N PANELS El MULTI-UNIT ❑STRUCTURAL.
z O r/V❑ 1 understand my plans shall he used as public records
MODIFICATION
024UP T02W AMPS
rr 41"M Licenced Professional - _ ❑INTERIOR ❑CHIMNEYREPAIR
J 2UI-IOdfIAMPS IMPROVF.MF.NT SWIMMING POOLS
,ej OWNER-BUILDER m Ce CorriON
dors
OVER 1000 AMPS ❑BATH REMODEVREPAIR O DEMOL N
OO Q 1 hereby affirm mm 1 am exempt from the Contfaders License Law for the p
O d U following reason.(Section]031 5,Business and Professions Code:Any city mentally SIGNS ELECTRICAL ❑OTHER
F O y which requires a permit le construct,alter,improve,demolish,or repair any sta clum
�.prior to its issuance,also requires the applicant for such Permit to file a signed statement SPECIALCIRCUIT/MISC.
yyWWythat he is)!ceased pursuant to previsions of the Conti s License Law(Chapter 9
tYiO� (commencing with Section 7")of Division 3 of me Business and Professions Code)or TEMP.MIT[C OR POLY COMMERCIAL:
that he is exempt therefrom and the basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION ❑DEMOLITION
"ted
,QH peSection 1011,1 by any applicant for, rmit subjects the...Bran 1.a civil penalty of POWER CF
❑TENANT ❑FOODSERVICE
N not more Nan five hundred dollars($500).p.
71
❑1.as owner of the property.or my employees with wages as their sole compensation I ING L E IMPROVEMENT
will do the wmk,ind theoricmre is not)mended.,offered fnI-to See.7 El OTHER
and Professions Code:no Cormorants License Law does not apply I a roof TL C - TUR
property who builds m improves thereon,and who does such work himself r"rough
his own employees,provided that such improvements are not intended or o W R LNTIAL L SQ FT. .
sale.If,however,the building or improvement is sold withthoneyem of cmapl i SQ.FT.FLOOR AREA $/SQ.PT.
owner-builder will have me totaled of proving that he did not build or imp rove pur-
pnsenfsalea - -
I,as owner of the property,am exclusively contracting with licensed omumc TOTAL: P A D
construct the project(Sec 7044,Business and Profess)ods Com:)The Conlmcto. M
cellae Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contacts for such projects with a contractor(s)licensed pursuant to the Contractors �� Q� �
Lice a Law. PERMIT ISSUANCE " 2
❑I ton rSeo. ,B&P C for this reason II '
Dote
ALTER-DRAIN&VENT-WATER(EA) (' VVALUATION
rte WC1ZKEfSrCOMNSATION DECLARATION BACKFLOW PROTECT.DEVICE
I hereby affirm under penalty perjury one of the following declaretinns:
El
Ihave and will maintain Certificate of Conserv to self-insure for Worker's Comped- DRAINS-FLOOR,ROOF AREA,COND. STORIES TYPE CONSTRUCTION
union,as provided for by Section 37M of the Labor Code,for the pernowame of the
work for which this permit is issued, - FIXTURES-PER TRAP
I have and will mountain Workers Compensation Insurance,as required by Section - -
37W of the Labor Code,for the performance ofthe work for which this permit is issued GAS-EA.SYSTEM-I INC.4 OUTLETS OCC GROUP AEN
My Workers Compensation Insurance carrier and Policy number are: -
CamieC Policy No,: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASOINDUSTRL WASTE INTERCEPTOR
(This section need ant be completed If the permit is nitrate h ditheddollars($100) BUILDING DIVISION PEES
or less.) GREASE.TRAP - PLANCHECK FEE
I certify that in the performance of the work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any Person in any manner so as to become subjectto the Workers'Compen- ENERGY FEE
�Z said.Laws of California.Date 10
WATER HEATER WNENT/ELECTR
y Applicant GRADING FEE
q y NOTICE TO APPLICANT:If,atter making this Certificate of Exemption,you should WATER SYSTENETREATING
F ; become subject to the Warker's Compensation provisions of the Labor Code,you must SOILS FEE
Lakl by forthwith comply with such provisions Or this permit shall be deemed revoked WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. $Q.FT. PAID
V Q I hereby affirm that there is a cnnswcoon lending agency fo meperformance of _ Dare ceipt#
W the work for which this perm!,Is issued(Sec.3097,Cm.C.) -
O Lenders Name OTAL:
r LUiI Lendce,Address TOTAL: -
1 certify that 1 have read this application and,state that the above information is BUILDING FEE
Fr rA correct 1 agree to comply with all city and county ordinances and slate laws relating to QTY, MECHANICAL PERMIT FEE
L) building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE
above-mentioned properly for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep handless the City of Cupertino against ELECTRIC FE
Imbilides,jadgmems,eostsand expenses which may many way came againsiond City ALTER OR ADD TO MCH.
in mnstmarce of the granting of this permit. PLUMBING F
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.011(1 CFM)
SOURCE REGULATIONS. MECHANICAL FE
AIR HANDLING UNIT(OVER 10.000 CPM) CONSTRUCTIONPAX
Signature of Applicant/Contmctor Dote EXHAUST HOOD(W/IIUCT) HOUSING MITIG ION FEE J
HAZARDOUS MATERIALS DISCLOSURE
Willthe ythe Cupertor nofMurebWlding Cue,Chaptswreor handle Health and Safety HEATING UNIT(TO IOO.IXq BTU) -
C defined io the Cupertino Municipal Crude,Chapter 9.12,and the Health and Safety
' Code,Section 25532(e)7 ' HEATING UNIT(OVER IW.WO BTU)
❑Ver F1 No VENTILATION FAN(SINGLE RESID) PAID "
Dote eeipt#
Will the air contaminants
m furore building by the Bt use equipment of dMana which BOILER-COMP(3HP OR 100,000 BTU)
emit havaaloua air cenwminams es defined by the Bay Area Air Quality Management TOTAL:
Dish fl
❑Yes F-1 No BOILER-COME(OVER I(1a,f1W BTU)
I have mad the hmmdous materials requirements under Chapter 6.95 of the Cali- AIB CONDITIONER ISSUANCE DATE
hale Health&Safety Code,Sections 255(15,25533 odd 25534.1 understand than Him NEW RESIDENTIAL.MECH. SQ.ET.
building does no,currondy have a mount,that it is my responsibility to notify the mcupan,
of the requirements which must be met prim to Issuance of a Certificate of Occupancy. ^y
Owner or authorized agent Date N,�r AL: ISSUED BY:
OFFICE
. .
ecit
10300 Torre Avenue
Cupertino, CA 95014
y of
Cupertino Building Division
(408)777-3333 (fax)
February 4, 1999
Homeowner
22674 Liberty Oak Lane
Cupertino, CA 95014
SUBJECT: Permit# S0788
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 CUPERTNO
Christy Akatiff, Administrative Clerk
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