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29637 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO. BUILDING DIVISION APPLICATIONIPERMITPLUMBING-MECHANICAL. Ill` BUILDING PROJECT IDENTIFICATION UILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE z s 'no 1+ -23-46 WN 'SNA PHO43 V%1 iiifta L&MJWr'A _� O RACI'OR'SN ME: ` I.IC NO: JI fq+�C SIC CONTROL N CHITECT/ GINEER: LIC NO: I RESS: ❑ I CONTACT: PHONE: El Consultant PERMIT INFO Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE 1 hereby affirm that I am licensed under provisions of Chamm pmr,9(coencing JOB DESCRIPTION aZ with Section 70 1 of Division 3 of Ne Business and Professions Code,and my license is DO 1 y PERMIT ISSUANCE RESIDENTIAL: I.full eores anti eRnt. �� ❑SFDWL' �ITCHEN REMODEL UzU License Class Contractor APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE rF 6 0. Dme Convector Orn ARCHITECT'S DECLARATION ❑MULTI-UNIT [I STRUCTURAL Z pt/�4 1 understand my plans shall he used as public records PANELS MODIFICATION CZ P-i UPT0 2M AMPS q ❑INTERIOR El CHIMNEY REPAIR Licensed Professional 201-1000AMPs IMPROVEMENT OWNER-BUILDER DECLARATION OVER 10010 AMPS R' I hereby affirm that 1 um exempt from the Contractor's License Law for Ne [I BATH RP.MOUEVREPAIR DEMOLITION 4 aU following reason.(Section]031.5,Business and Professions Code:Any city or county SIGNS ELE,t aICAL ❑OTHER C^ which requires a permit m construct.alter.improve,demolish,or repairany smucmre PH.".I., requires the applicant for such pewino file a signed eammem SPECIAL CIRCUIT/MISC. that he is licensed pursuant o the provisions ofibe Contractor's License Lmw(Chepter9 qC (commencing with Section 7")of Divivim 3 ofihe Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL: that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION Section 70.11.5 by any applicant for a permit subjects the applicant to a civil penally of POWER DEVICES m TENANT ❑FOOD SERVICE p, not more than five hundred dollars y employees C ❑Las ownerhe thenostrum. is etimmuledminiwages ned far Nei(See74,Businesson, SWIMMING POOL ELECTRIC IMPROVEMENT and do the work,and the he Cont is not intended oLa w do for sale(See to an Business OTHER pro Professions Cale:The Contractor thomr's License Law saes not apply to if .hoer of OUTLETS-SWITCHES-FI%TURFS his own who builds or improves thereon,and who does such work himself m through his own employeese building that such mens is seold within ere not inmWmc.r offered for NEW RLSIl3ENT1AL ELECTR SQ FT. sale.ILhawevegtheveth bur improvement[sat hedidonoild or improve SQ.PTeFL(��R AREA S/SQ.fT. owner-builder will have the burden of paving that he did not build orimpr.ve for bur- ' ( P fiT poo o(suleJ. C as owner.(the pr.peny,am exclusively connecting with licensed mmvca rmto TOTAL: APR nswetthe pro (gee.]044.Business and Professions CWe:)'I'he Convectors Li- %�J fj cenu Lew doesmeeppiyman.wnerofpuiperty whibrolds orimprnves thereon,and QTY, PLUMBING PERMIT FEE t� 9g who contracts for such pmjems with a contractors)licensed pursuant the Contractor's k, License Luw. \ PERMIT ISSUANCE '/�y Vf• ❑Iantempt under Sec. ,B&PCTs Nisreamn CY(lOL! ALTER-DRAIN&VENT-WATER(EA) VALUATION wn Damifilgai COMPENSATION OECWIRA'f10N BACK FLOW PROTECT.DEVICE 1 hereby affirm under penalty of perjury one of the following decimations: ILuv.and will maintain a CertifctcufConsent t.self-insure for Worker's Copper- DRAINS-FLOOR.RUDE,AREA,COND. STORIES TYPE CONSTRUCTION aeon.as Provided far by Section 3]00 of the"No Cede,for Ne performance of the work for which this permit is issued. FIXTURES-PER TRAP ❑I have and will maintain Wmkers Compensation Insuranceas required by Section "00.f Oe Labor Code,for Ne Nrfomune.ofthe work for which this permit is issued. GAS-PA.SYSTEM-I INCA OUTLETS OCC.GROUP APN My Wmkers Cmnpensation Insurance carrier and Policy number are: Cariee Policy No.: GAS-EA.SYSTEM-OVER 4(EA) CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREASEiINDUSTRL WASTE INTERCEPTOR (This section need not he completed Rate permit is for one hundred dollars($hap) BUILDING DIVISION FEES or lcss) GREASE TRAP PIANCHF.CK FEE I certify that in the perfowamenfthe work fm which Nis pewit is issued,[shall SEWER-SANITARY- not employ an STORM GA.2W PT. p y y pecam in any manner sous to become subjecu.the Workers'Cnmpen- ENERGY FEE 0Z when Laws of California.Date WATER HEATER WNENTMLECTR 7 12 Applicant GRADING FEE F7 V2 NOTICE TO APPLICANT.If,after making this Certificate of Exemption,y..should WATER SYSTEM/TREATING a SOILS FEF.5 become subject to the Worker's Compensation provisions of the Lahor Code,you must W forthwith comply with such provisions or this pewit shell be deemed mvokW, WATER SERVICE Q CONSTRUCTION LF.NDING AGENCY NEW RESIDENTIAL PLMH. SQ.fty'. PAID V Q Iforhereby which hi that iso issued ion lending agency for performance of Data Ru prN W. t+ the work for which chis pemtit is issued(Seo.3fW].Civ.CJ 0 1F--�� Landee,Name TDTAL: Lenders Address TOTAL: 0. I cenify Net 1 have rtes Nia application and state that Ne above information is BUILDING �. fA arrtect.1 agree to comply with ell city uW county nNinances unJ stmt lows relating to QTY, MECHANICAL PERMIT FEE U Zbuilding comwetion,and hemby vothodsrtpresentativesof Nis city metncrupan the SEISMIC d ide v-mamioned property for inspection purposes. (We) Me to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE Imbilities,pagmcnts costs and expenses which may immy way swemeegainst said City ALTER OR ADD TO MIiCH. in consequence of the granting of this pewit. PLUMBING FEF. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0ID CPM) SOURCE REGULATIONS. MECHANICAL FEE AIR HANDLING UNIT(OVER 10,010 CFM) CONSTRUCDON X Signature.(Applican/C.ntmcmr Date EXHAUST HOOD(W/DUCT) HOUSING MITIG ON FEE HAZARDOUS MATERIALS DISCLOSURE Will Neapplicant or fare.buildiro,ccupumsmmm handle Strontium,unclear] HEATING UNIT(1010.000 BTU) as defined by Ne Cupertino Municipal Code,Hope,9.12,and the Health and Safety Code,Section 25532mL HEATING UNIT(OVER 100.000 BTU) ❑Yes ❑No VENTILATION PAN DINGLE RFSID) PAID Wdl the applicant or fawns building ociapam use equipment or devices which Dam Receipt p hmzmdous air contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP(BHP OR 101,000 BTU) TOTAL: ct? BOILER-COMP(OVER 100,1100 BTU) ❑Yen ❑No I have read the hmardms auditors AIR CONDITIONER rcquiremenu under Chapin 6.95 of the Cali ISSUANCE DATE humin Health&Safety Code,Sections 25505,25533 and M534.I undersand that if the NEW RESIDENTIAL MECH. SQ,Fr.. building dna nm currently have a moral,that it is my responsibility to notify the occupant of the restatements which most be met prior to issuance of a Cenifeam of Occupancy. Owner m auNodud agent Use TOTAL: ISSUED BY; OFFICE 10300 Torre Avenue ecitvci, Cupertino,CA 95014 C1tpeithll 0 Building Division r (408)777-3228 (408)777-3333 (fax) June 18, 1997 Homeowner 21566 Monrovia Cupertino, CA 95014 SUBJECT Permit#29637 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 Pnntua on Pecvrled Paper