30129 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. O 1 Z V
BUILDING PROJECT IDENTIFICATION
BUIf.U1NG ADDRESS: SANITARY NO. APPLICATION SUBMI'I-IAL DATI
aoo.�. �rswits; 5� z7�
OWNER'S NAME: c- PHONE: CONTRACTOR'S NAME: LIC NO'.
J4JljUiFf(QQL A4T-4( Vdam^ he B�i-a NIC CONTROL#
\IiCHITECT/ENGINEIiR: LIC NO, ADDRESS: ❑
480 SC. 0~1.18l 09
CONTACT: PHONE: BUILDING PERMITINFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG LF.CI' PLU 1B MECH
LICENSED CONTRACTOR S DECLARATION QTY
ELECTRIC PERMIT FEE
I herehy affirm thin 1 um licensed under provisions of Chapter 9(commencing JOB E$CRIPTION
'00OZZ ith Section]00)ofDivlsiun 3 of the Businessland Professions Cade,call illy lectsse is RESIDENTIAL'
F W. in w full force and effect. PENMI'1'ISSUANCE,
=UF II,..<Claa Cao Lic,p OYX Q, ❑SFDWL El KITCHEN REMODEL
Q U APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
ZW Data
v - Centmeer
A 11ITECTS DECLAR DON ❑MULTI-UNIT ❑STRUCTURAL.
Z O N
, to
I undmmnJ my plans shall M used as public ascend. PANELS
MODIFICATION
oZ=o UP TO 200 AMPS I C1 INTERIOR [I CHIMNEY REPAIR
W Licensed Pmfcen.a.l 201.1000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER 1100AMPS ❑BATH RHMODE1lREPA1R [I DEMOLITION
Q 1 hereby affirm tbtn 1 am exempt from the Contractor's License Law for the
x1 DyU following award,(Section]031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
ul 3 O H which requires o permit a construct,alter,improve,demolish,or repair any structure
Lp"�s
�ssQ prior a its issuance,also requires theapplicaut for such permit to rile a signed statement SPECIAL Cl RCUTUMISC.
2 W)"") that he is licensed pubmanno the provisions of the Connector's Llccnse Law(Chuper9
WT=00 (commencing with Section70MBUDivision 3ofthc Business and PmfewioryCore)m TEMP METER OR POLE INST COMMERCIAL'
a a e C that he is exempt therefrom and the basis for the alleged caemptioo.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 70315 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
NZps notnwre Wet frvc hundraddollms(550). IMPROVEMENT
=6 (]l,as owner ofthe p.pert,or my employees with wages as their sole compensation. SWIMMING POOL ELECT RI
S,LJo th
C will e work.and structurem
the structure is not intended uffered for same(Sec.7014.Business [I OTHER
13 m and Professions Code:The Conhmasrs License Low does not apply to an owner of OUTLETS-SWITCHES-Il
property who M1uilds or impfnvcx nation,and who coca such work lonowlf er through
his own employees,provided that such imprevemctns are not intended or offered for NEW RESIDENTIAL ELEL
sale.If.however the building or improvement is sold within one year ofcompletion,the SQ.IT.FLOOR AREA 5/SQ.FT.
..per-builder will have the bunds.of proving that he did not build or improve for par.
"m of soled.
p 1.as ownor of eche propcny,am mofavively contracting with IiaenseJ ttmtmcers m 1i
construct he project(Sec.7IH4,Business and Professions Code:)The Contractor's Li- /��
c s. law does not apply to an owner of progeny who builds or improve ronINC,therand QTV PLUMB INPERM IT V O7
whit contracts for such projects with in cmnuacaodq licenced purourand to the Contractors 4i
License Law. PERMIT ISSUANCE \�(r X991
❑1 am exempt under Sec. .0&P C for this as . (�/ f
Owner Dae ALTER-DRAIN&VEST-WATER IFA) VALUATION:,J
WORKER'S COMPENSATION DECLARAION BACK FLOW PROTECT.DEVICE a k
T
I hereby affirm under penalty of Perjury one of the follnwing declarations
•D[have and will mainmine Cenif me ofConscnnn ulf-insurt for Workers Compel- DRAINS-FLOOR.ROOF,AREA,COND. STORIES TYPE CONST RUCTION
anion,as provided for by Section 3700 of the Labor Code,for the#compliance of the
work for which this permit is issued. FIXTURES-PER TRAP
I have and will maintain Workers Compensation Inmmnce,as required by Section
37M of the labor Code,fill Performame of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUT' APN
My Worker's Comptivold surmarm eamerand Policy number are
Curies fT Policy No.: /2 z3 -s GAS-EA.SYS'TEM-OVGR4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASETNDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This section need not be,completed irate Permit is fertile hundred dollars IS 1(0) GRGSETRAI'
or Ices.) PLANCHECK FEE
a [certify throat the performuncenr Wu work fur which this proal',issued,[shall SEWER-SANITARY-S ORM EA.200 IT,
and employ any person in any manner so as to become subject to the WmkenCompel- ENERGY FEE
Z Basion Laws of California.Date WATER HEATER WNENT/ELECfR
-4 O Applicant GRADING PEE
NOTICE.TO APPLICAN'1'.If,after looking this CertiOeae ill'Exemption,you should WATER SYS'l FhTTREATING
la ; become subject a Worker's
the Cmnpctautien provisions of the Labor Code,you must SOILS HE
fonovith comply with such Provisions or this permit shall be deemed evoked. WATER SERVICE
6
UO CONSTRUCTION LENDING AGENCY NIiW RESIDENTIAL PLMB. SQ.FT. PAID Date Receipt#
1 hereby offrnvhm there in a mngmaion lending agency far theperformana of
U. r the wmk for which,his permit is i..ed(Sec.3W7.Civ.CJ
V1<nders Name TOTAL:
Lender's Address TOTAL:
FI certify shat 1 have end his nppfc.tinn and cmc ohm the above inrnnnmtoo is BUILDING ITE
rq cambf.I agree to comply with all city and county ordinances ordinate laws refining to QTY. MECHANICAL PERMIT FEE
V Z building csmsuuaionand hereby amhmixrspressinsivesofthis city.emer upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE. ELECTRIC FEE
(We)agree to sive.Indemnify and keep hunnlen'the City of Cupanito against
Iiabildiesjudgments.costa and expenses which may in any way nerve against said City AIT ER OR ADD TO MF.CH. PLUMBING FEE
in aonsoc amse of the Grunting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,000CP10) CONSTRUCT ION TAX
Signature of Appllcam/Commaor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplieamorfuture holding twcupeal semorhandle haenrolnus materirl HFA'1'ING UNIT(TO I09),(001iTIJ0
as defined by the Cupertino Municipal Cade.Clm m,9.12,and the Heald,and Safety
Core,Section 25532bf? HEATING UNIT(OVER If0.f00 BTU)
[]Yes E_]No PAID
VFMILAT'IUN FAN(SINGLE RESIU) Date Receipt N
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HPOR 100.00 BTU) TOTAL:
Dismal? BOILER-COMP(OVER 101.00 OTU)
F-1 Yrs [-I No
I have sad the Iocrumbse,..,coal,begamentems under Chapter 6.95 ofthe Cali- AIR CONDITIONER ISSUANCE DATE
fomla Heaps&rSafetycure Code,Sections 23505,25511 and 255)4.1 o.dersmnd that if the NEW RESIDENTIAL MECH. SQ.Fri.
huildin6 J:ua nm curzcntlY have aen:nv,aha it Is my resp
to Certificate
ecoreifythe
per, n
of the rcmen/Ls/�/tM1icM1 mustbe .prima°'�s inose ofaCenilicae of(kcupancy.
Own uuthurieed ugem Dam TOTAL ISSUED BY:
OFFICE
CC
i} nl' 10300 Torre Avenue
Cupertino,CA 95014
c
Cupertino Building Division
(408)777-3228
(408)777-3333 (fax)
January 22, 1996
Homeowner
20052 Northcrest Square
Cupertino, California 95014
SUBJECT Permit: #30129
Dear Homeowner:
We have been cleaning out our files in the Building Department, and contacting those
people with permits which have remained"open".
• According to our inspection records, the subject permit has never been finaled. Many
times an inspector will sign the permit in the field, but neglect to report all of the
information to the clerical staff for input into the computer. If your records show the
subject permit as finaled, would you please contact us so we may complete our records?
If the permit is not signed off your permit can be reactivated and an inspection could be
scheduled for final closure of the permit
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
•