30369 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
,CITY CIF.CUPC'RTINO BUILDING-ELECTRICAL PERMIT NO. 3 0
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHAN'IC'AL
BUILDING PROJECr IDENTIFICATION
BUILDINGADDRESoS:� SANITARY NO. APPLICATION SUBMITTAL DATI
"0- O laz*w /20x89
\ OWNER'S NAME: PHONE: CO,,yRACTOR'S NAME: LIC NO:
1-17hrzloz- 101465 2 //i4m7 ..c_0�1G/� LJS�J vsf /J N/C CONTROL#
%RCHl'I EC'VENGINEER: I.1C NO: ` ADDRESS rl ^L/ !/ ❑
ru
CONTACT: PHDNE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ I/aSy J`T
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm Nal 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
WOO h Soo with 7000).f Division Softhe BminessanJ Professions Comr.and my license is RESIDENTIAL:
WPERMIT ISSUANCE
in lull force end offs ❑SFDWL ❑KITCHEN REMODEL
aUU Lscn.ve Clvss Lic.# APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RU-PIPE
V W Data Contrxcfof
A I'ECI'S D[CLARA'i'ION ❑MULI'6I1NIT ❑S'i'RUCI'UkAI.
Z 00 Z 1 unJ ..and my plans shall be used as public records PANELS MODIFICATION
�+ UPTO 2(O AMPS
OZ-0 [I INTERIOR C1 CHIMNEY REPAIR
¢vsF; Li¢nsed Rvfessional 201-I000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION
Y k w OVER IqO AMPS ❑BATH RE jnIl12EPAIR 0DEkdOLITION
KC tY Q 1 hereby affirm that 1 am exempt from the C ssions o :License law for the
3 p,U following recon.(Section]onstru t.almsa and Professions Code:Any city st county SIGNS ELECTRICAL []OTHER
!]4 O H which requites a permit re consumer,applicant
improve,demolish. file
repair any mmcmrt
_
Poor to incensed pursuant
requiresto he thevisams,o for suchpermitLicense ned aw(Ca statement SPECIAL CIRCUIT/h115C.
R�Ny Nm he is licensed pursuanumtbe provision of the Contractors License Law(Chapter
0 (commencing with Section 7000)ofDivision 3 of the Business and Professions Cada)or TEMP.METER OR POLE INST. COMMERCIAL:
1 q o K that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W Zo Section 71131,5 by any np,l,,u.,for.peani,,miaocLuhe applicant ton civil penin,of POWER DEVICES []TENANT ❑FOOD SERVICEFZY�
not more than live hundred dollars($500) IMPROVEMFN'I
f�0 ❑ Las owner fthe Prol'emy,or employers with wages as their solccnmpemmion, SWIMMING POOL ELECTRIC
F, will do the work.and Ne structure is ot intended or offered for sale(See.7044,Busmr%s El OTHER
{mil and Professions Code:The Contractors License Law does nor apply to an owner of OUTLEfl-SWITCHES-FIXTURES
3 property who builds or improves ib,xon,and who does such work himself or through
his own employees,provided that such intpravement are not in¢ndcd e,offered for NEW RESIDENTIAL ELECfR SQ
sole.If.however.the building or improvement is sold within one year ofrompletion.the SQ.FT.FLOOR AREA SISQ.FT.
ter-builder will have Ne burden of proving that he did not build or improve for par-
"se ode.). a '
71 1,us owner of the property,am exclusively contracting with licensed contractors to TOTAL:
consumer Nc project(Sec.7044.Business and Professions Code:)The Contractors Li- a
Cj
c sec larw does not apply to an owner of property who builds or improves therum,and QTY. PLUMBING PERMIT FEE ..r D
whoummaa,Tormuch prnjeas with scout club,)licensed pumunt(,,,he Cnnolaars 1(I
License Law. PERMIT ISSUANCE 1779[1
1 vat exempt ander,Sec. ,B&P C for this mason (d
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date •,U
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the fallowing declarations:
I havemnd will maintain a Certificate of Consent to xlfmum for Worker's Compeer- DRAINS-FLOOR.ROOF AREA.COND. STORIES TYPE CONSTRUCTION
,tion,ox provided for by Section J7W of the Libor Code,for Ne performana of Ne
t for which Nis permit is issued. FIXTURES-PER TRAP
.have and will maintain Workers Compensation Insurance,as required by Section
9700 of the Labor Code,for the
ppedinuence of the work for which this permit is issued GAS-EA.SYS TEM-I INC.4 OUTLETS OCOGROUP AVN
/ Carrier:k �-`Ga n�eA* /,arri ynl'ud YNaY n "1 GAS-EASYSDiM-OVER4TAO
CERTIFICAI'11017 EXF-MPl'ION FROM WORKERS' GREASUINDUS'I RL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(IhissatinnneednabecnmpletWifNcp mitisfornnehund"dnllan S100) GREASETRAP
su less.) PLANCHT:CK FEE
I candy that in the performance little,work forwhich this permit is issued,l shall SEWER-SANITARY-STORM FA.200 FT.
not employ any person in any manner so as to become subject to Ne Workers'Compeer- ENERGY FEE
Z motion Laws of Califomia.Dae WATER HEATER W/VENT/ELECfR
z 0 Applicant GRADING FEE
NOTICE TO APPLICANT:If,after making this Ccnifmate of Exerb,rmt,you should WATER SYSTENINREATING
a ; become subjectthe Workers Connpemation provisions of the Ialan Cole,you must SOILS FEE
{✓•1 fnnbwhih comply wird such pbou,inaor rhispormht shall be deomed revoked. WATER SERVICE
Q
p" CONSTRUCTION LENDING AGENCY NEW RESIDIiNI'IAhi'hMB. SQ,PI'. PAID
U 0 thereby affirm that pe
hem is a cmnamction lending agency for the rformance of Data Rcceiptp
l!. P" the work iia which this permit is issued(Sea 3097,Co,C.) TOTAL:
0 U U.dcex Name
Lendsex Address TOTAL:
M. I certify Nat 1 have read Nis application end state that the above information isl,i BUILDING PEE
M.
UZ burdingco xemcomply
and hereby city atlari county
ntsiveecsand Stam lawsenter
gm QT}'. MECHANICAL PERMIT FEE
UZ building construction,and herby authorise xpmxnmtives of Nis city to enter upon the SEISMIC FEE
aMwe.mrnioned property for inspection purpres. PERMIT ISSUANCE
(We)vgme to save,indemnify and keep harmless Ne City of Cupcnina ll,ma i ELECTRIC PEE
liabilities,judgments,costs and expenses which may in any way arrive aguinsisaid City ALTER OR ADD TO MECH.
PLUMBING 1>GE
in 4e of thegranting thm
b perit.
APPLICANT UNDERSTANDSSAND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNII'(TU 10.000 CPM)
MIiCHANICAh IIeG
SOURCE REGULATIONS.
AIR HANDLING UNIT(OV[R 10,001 CFM) CONSTRUCTION TAX
Signmumof ApplicanuCommctor [)ate EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Willlheapplicamarfuture building Bacuprtmommr handle heallous material HEATING UNIT(TO 110,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cute.Section 25532(x)? HEATING UNIT(OVER 110.000 BTU)
❑Yen ❑No VENTILATION FAN(SINGLE RESID) PAID
Date Receipt#
Will he upplheam or future huilding occupant use equipment or devices which
Til hazardous nit conwmin.nta as defined by the Bay Arca Air Quality M.nagemcnt BOILER-COMP QHP OR 100,00K)BTU)
rornl:
rier4 BOILER-COMP(OVER 100,000 BTU)
E]Yes F7 No
I have read the M1 mous materials requirements under Chapter 6.95 of the Cali. AI R CONDI'T'IONER ISSUANCE DATE
burns Health&Safety Code,Sections 8505,25533 nod 25534.1 undroiand that ifthe NEW RESIDENTIAL MECH. SQ.ET.
building does not combrady have a tenant.that it is my responsibility to notify the occupam
of Ore rcquiremrra which mum be met prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Date JI ISSUED B
OFFICE /
l�� of, 10300 Torre Avenue
Ci
Cupertino,CA 95014
k"LLPeltino Building Division
(408)777-3228
(408)777-3333 (fax)
June 18, 1997
Homeowner
22049 McClellan Rd
Cupertino, CA 95014
SUBJECT Permit#30369
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
Printed on Recycled Paper