30768 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION ., APPLICATION/PERMIT PLUMBING-MECHANICAL: - � 30768
BUILDING PROJECT IDENTIFICATION
• BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
'' S � � Loci-CrOR'� . cam
OWNER'S NAME: PHONE: - CONTRACTOR'SNAME: LICNO:
�•I.�YZI 31 � � N/C CONTROL is
'+CHTTECT/ENGINEER: . LIC NO: ADDRESS /I - 34O p 9, z. Li {
O!CESS `tlur�
J a,C-/r �
ONTAC`E PHONE: ,. - BUILDING PERMIT INFO
,❑ Consultant Fees Paid by Applicant(Initial) - BLDG ELECT PLUMB MECH
vIC--T-f I-, ado-?T716 El Pa! El ❑ .
LICENSED CONTRACTOR'S DECLARATION' QTT ELECTRIC PERMIT FEE s
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing LOB DESCRIPTION
DZ with Section 7001fof Division 3oftbe Buordoand Professions Code,and my feemels L RESIDENTIAL: ;
a in full force and efor - PERMITISSUANCE ^l
Q U�" License ass ��'8 Lie p v`�C-7 0 - SFOWL [I KITCHEN REMODEL
UU C,1 APPLIANCES-RESIDENTIAL
W� Date / —Contrac or CADDITION C PLUMBING RE-PIPE.
ARCHITECTS DECLARATION PANELS
F 5 rn El MULTI-UNIT []STRUCTURAL
O Zp v-7, 1 understand my plans shall be used as public records /I /I MODIFICATION
UP'T0200 AMPS �+A/ INTERIOR' • ❑CHIMNEY REPAIR
F4 I�il Licensed Professional -OWNER-BUILDER DECLARATION 201-1"AMPS IMPROVEMENT
'fig` Taj
xyy d hereby affirm Churl em exempt from the Contractor's License Lew for the OVER 1000 AMPS ❑BATH RF.MODEVREPAIR 0 DEMOLITION
W 3 G F following moved,(Section 70315,Business and Pmfessinns Code:Any city or county C OTHER
LL7 u. which re p p y s SIGNS ELECTRICAL
� y¢ quiresnpermit re cores thealter,intmsech perm fi,orre sire tmcmin r
rn.i Amor to its issuance,also requires the applicant for such permit Ole aligned statement SPECIAL CIRCUIT/MISC.
p. that he is licensed Formula a the Provisions of The Contractor's 1 L (Chapter 9
OC (cum g with5 t 9000)fD 3 fth-B and pries Code).,. TEMP.METER OR POLE INST. COMMERCIAL, '
0.y oa that he's exempt therefrom and the basis for the II g d exemption Any violation of
itrok. Section 70315b n applicant f pp ❑NEW BLDG/ADDITION L1 DEMOLITION
W Y Yrepermit subjects the Ilam to a civil penalty of POWER DEVICES CTENANT CFOOD SERVICE
E, g. not mom thea❑vs,hundred dollars($SOLI). IMPROVEMENT
OC1,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC '• -
will do the work,and the structure is not intcndedoroffered for sale(Sec.9044,Business ❑OTHER
Ym and Professions Code:The Cearaatnr's License Law does not apply toga owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements we not Intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If,however,the building or improvement is sold within one year of completion,the SQ.IT.FLOOR AREA $/SQ.FT
owner-builder will have the burden of proving that he did not build or improve for par-.se.fA ' D
El posule.),
I,as owner of the property,am exclusively contracting with licensed contradicts to - TOTAL:
construct the project(Sec.9LW4,Business and Professions Code:)The Contractors Li-
comeLawdoesnotapplytoanownerofpropertywhobuildsorimprovesthereo,and QTY, PLUMBING PERMIT FEE IAAI A nF.nr�
who contracts fnr such projects with a commete6s)licensed piantio Oothe Contractor's AERN 4 IICb
License Law. PERMIT.ISSUANCE
❑l am exempt under Sea ,B&P C for this reason '
Owner - Dale ALTER-DRAIN&VENT-WA (E Up kotmm'ry
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE -
Iherebyaffirm under penalty ofperjury one ofthe following declarations:
I have and will maintain n CmiEcateofConsent to self-insure fear Worker's Compen- DRAINS-FLOOR,BOOP,AREA, U STORIES TYPE CONSTRUCTION
inn,as pr ided for by Section 37M of the Labor Code,for The performance of the
work( icll this permit is issued. FIXTURES-PER TRAP r
ave and will maintain Workers Compensation Insurance,as required by Section f
3900Mthe Labor Code,for the performance of the work for which this permit is issued. - GAS-EA.SYSTEM-1 INC.4 OUTLETS DEC.GROUP APN
MyWor�r� Compensation Insurance carrier and Policy��nWtRnnbu arc
CartietL2ilk�^Y..1 Policy Ne:NVJLBOl.59 GAS-EA.SYSTEM-OV
ER4(EA) r r .
CERTIFICATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
.l llRls section need not M1ecomplded disallow isPomne hundred dNlars(SI W) GREASETRAP L�
BUILDING DIVISION FEB
less) PF ANCH. FEB
Toys,Natio the performanceof the work by which this the WiisissuCmar,aa11 SEWER-SANITARY,STORM EA.200 FT. -"
not employ any person w any manneno as o become suhjed to the WorkerK Compete ENERGY FEE
0 A,pli Laws of California.Dam
�O A licant - WATER HEATER WNENT/ELECTR '
pP GRADING FEE
Tj NOTICE TOct 0 da,ANTi If,aftermaking thiscolown, I the
Exemption,you should WATER SYSTEM/TREATING
become subject y the Worker's Compensation provisions of the onbor Code,you must SOILS FEE
forthwith comply with such provisions ur this permit shall be deemed invoked. WATER SERVICE ..
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT. PAID
V l hereby affirm that there is a construction lending agency for the performance of Date •RaeiPtN
,,a H the work for which this permit is issued(Sec.3097,Civ.C.)
0 Lender's Name" TOTAL:
WLender's Address TOTAL:
I certify that I have read this application and state that the above information is BUILDING FEE
TA comet,l agree to,comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
�j
U G building construction.and hereby authonze representatives of this city to enter upon the SEISMIC FEE
above-mentioned pmpery for inspection purposes. PERMIT ISSUANCE
(We)agree unitive,Indemnify and keep formless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way wards,against said City ALTER OR ADD TO MECH.
in of gn PLUMBING FEE
onsequenceo grentin of permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0011 CPM)
SOURCE REGULATIONS. - MECHANICAL FEE
AIR HANDLING UNIT(OVER IO,I)DO CFM) CONSTRUCTION TAX
Signature of Applicant/Cmitactor Data EXHAUST HOOD(W/DUC1) HOUSING MITIGATION RE
MATERIALS DISCLOSURE.
Willtheappliewc.,future building dccdpantsmreor handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cade,Section 25532(a)9 CHEATING UNIT(OVER 100,000 BTU)-
. ❑Yes L]No PAID
s VENTILATION FAN(SINGLE RESID) pate, Receipt N,
Will the applicant or future building occupant use equipment or devices which it hazerdous it contaminants as defined by the Bay Arco Air Quality Management BOILER-COMP QHP OR 100,1100 BTU)
TOTAL: s
hint? BOILER-COMP(OVER 100,000 BTU)
❑Yes No - -
r
ad the lineations mammals re uircmem,under Chapter fi95 of the Cali- AIR CONDITIONER
m .
9 p ISSUA CE ATE q t
to a Health I c rte ly Sections 25505,25533 and 25534.1 to notify the
Nat if the NEW RESIDENTIAL MECH. SQ.ET.
dding do Ic(brrently hu :etutaut,Ihel hJsmy msponsibilitymnotl(y are occupant
I e tom L ch srxprixpto esuaneciefa Cenificatenfor pa -
w mauthriz a Dm TOTAL: ISSUED BY:
OFFICE
® 10300 Torre Avenue
Cupertino,CA 95014
Cit} of
Cupertino Building Division
(408)777-3228
(408)777-3333 (fax)
June 18, 1997
Homeowner
7566 Lockford Ct.
Cupertino, CA 95014
SUBJECT Permit#30768
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 had a final inspection.
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 dispose of the file and remove the records from our computer.
Thank you for your assistance.
Sincerely,
CITY OF CUPERTINO
Christy Akatiff, Administrative Clerk
Pnnlad an Pecycled Pape.