S 1887 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY QF CUPERTINO BUILDING-ELECTRICAL PESfr NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING.-MECHANICL
1887
I4UILI)ING PROJECTIUENTIFICA'PION
BUILDINGADDRESS: e /�O %�� ��b/� SAN]IARV No, APPLICATION SU13MI'I-I'AI.PAT 1;
ZZ-3-70Pa/m AteVuP. 7- z,:, :�? g
OWNER'S NAME: M /1,,yy PHONE; CO NI'RACI ORS NAME: LIC NO:
,ovri,iq /- rc C,Is�r —_77� NIC CONI RDI,p
\RCIIITECI'/ENGWfiER: n LIC NO'. ADDRESS: ❑
C...
oNTACL PHONIi: BUILDING PERMIT INFO
/TDMA /(�U ?LY411 944-6&e71 ❑ Consultant Fees Paid by Applicant(initial) HI❑DG EIJEC' PLUMB MOi
LICIiNSI?DCONTRAGIOR'SDECI,ARATION QTY. ELECTRIC PERMIT FEE
1 hcrehy arrrltt than I a,,,he ed ower provia mI,of chapter 9 dommeecing JOB DESCRIPTION
a0Y websicef i700d)nfUlvlsion 3ofine Buxinc n and Prote,,ium Code,aud Tyl lmnse is RESIDENTIAL:
H full lime and cfoO. PIIRMI'I'ISSUANCE —0
400 in ❑mTYAL LD KITCHEN RIiMODEI.
FQE.ZFULicense Clue,
Con rumor APPLIANCES-RESIDENTIAL ❑AUDITION ❑PLUMBING RE-PIPIi
e
yQq ❑MULTI-UNIT �STRULTURAL
T.D. ARCHITECT'S DECLARATION PANELS MODIFICATION
yzw Z I nuderxtand my ILmx shall he used its public records
v,O UP 1'0200AMPS ❑TNT ER10R ❑CHIMNEY REPAIR
Licensed Professional 201-1000AMPS IMPROVEMHN'I ❑SWIMMING POOLS
OWNER-BUILDER DECLARATION OVRR 1l1f0AMPlS E3BATH REMODEIIREPAIR C]DEMOLITION
C Q I hereby afGmt that[.am exempt from the Contractor's License Law for the
iyC
GU following m m.(Sellk 711315,ISnxinen and Pmfes ,Cede Any city o county SIGNS ELECTRICAL ❑OIHF.R
li]'3 W y which rect ims a p,,,tlll lu canstrurY,uhcr.`impmvq r can into our repair any slrncYnre
�Qi prior to its issuance.also requires the applicant for such permit to filcasigaed.wmement SPECIAL CIRCUI'I'IMISC. U
E�} that he is licensed pursuant biros provi.sionso'the Contractors License law OChapmry COMMERCIAL'
C) (commencing with Section 00
ed Di vision 3 of the Business and Profession.Gale)or 11;M RMETFRORPOLEINST.
q q e C the he is exempt threctrein and the kris lin the alleged uxeulpdon.Any vi( in of ❑NBW BLDG/ADUITTON ❑DEMOLI'UON
Xmq Section 7031.5 by punnil Bub mtn the applwent lu rte,,!I POWER DEVICES
WAN y arty:gGplisam litre i [I TENANT ❑FOOUSIHtVICI3
not more than five hundred dollars(55001. IMPROVEMENT
E=O ❑has lwrler of the Pmpeny.or mYcmployces with wase.as theirsolc our section, IMMIN 1. '
❑OTHIiR
(.. will do the work.and the%fracture is not intended or offered for sale(See.7 _
G 3 w and professions Cede:She Contractors License Law docs not epply a a ton Ol1TL 7 1 INTO
fill
property whit heilds ur improves themon,end who doe.such work himsol Through
his own employees,provided that such Intpmvemenly um nut intended o lin I?W lid :N'I'T E 'f.
sale.Ihixevec the holdinguf imm
prnvcnm is sold ss'iminne lyemofcn SQ,1.7.FLOOR AREA $ISU�FT
l:
mamer-buildeT will have the burden x proving lye t h did g w build p for pun Y U �RED
f ).
1 f ll(See it ss T exclusively t .I 0sM1 licensed t Genre to
nulf 11 l) 1 apply
t,an H J dsd )T C t an,I.
,cl J rpplyl fp pent h builds I :th vvt and QTY PLUMBING PkiRM111T PE.
who comracnfor such projects with a Commands)licensed pursuant to the Contractors
License Law. PERMIT ISSUANCE
❑ aG scoot ander See. .B&P C for this reason
AIA HR-DRAIN&VENT-WAT];It(EA) VALUATION
OwnGltc I e —/F-tlYY'V-lt
WORK. 'OMPIiNSATION DECLARATION ^ - f V BACK FLOW PRO]EC..DEVICE
I hereby affirm under penalty of perjury one of the following declaratinm:
J I have and will maintain a Certificate of Consent to xd6 insure for Workers Compo- DRAINS-FLOOR,RO FF.ARIi .GOND. STORBiS TYPE CONSTRUCTION
Ilion,us provided In by Sucban 3700 of the Labor Code,for the Thedunnnnce of the
ssork for which this pcnnn is Nluvol. Il%'TURBS-PEIt'IRAY
F1 I have and will maintain Worker's CnmlGen ation Insurance,as required by Section
37M oftbc Labra Code.lin the perfomtance ofthe sunk four which this Permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCG GROUT' NPN
My Worker's Compensation Insurance owner and Policy number arc:
Currice I'They No.; GAS-CA.SV$'11iM OVER 4IIiA)
CERT I FCAFE OP CXENUI ION FROM WOR KIIRS' OR 17ASIIIN DUST ST.WAS 117 IN'IIiRCEPIT)to
COMI'IiNSRFION INSURANCE BUILDING DIVISION FEES
(His sectionneednut bccomplemd ifine permit is for one hundred du[].Sign GRHASETRAP
PLANCHECK TIE
Ii
I wninythin
"'IT'he t y o,,manccofthe I,to bekhernem ndbhtloderW..ks.med,lelmt SIIW ER-SANITARY-STORM F;A.2N)IT
tut employ nrGY Terse .'ny yo,,t ....x to becunu xuhio'1 m the Woded Gnitlpel: IiN1iRCY W.E
OZ satinn Laws o1 CuGfornit [)atea WA'117R HEATER W/VENDELEMR GRADING IIiF:
O Applicant
(n NOTial*TO APPLICANT:If,arm,making this Ccnificate of Exemption,you should WATER SYSTEMPUREATING SOILS FEE
F feeamc Banded w Tho Workers Coutponsmiom pmvi,mr,cf thu Iybnr code, not most
lx arthwidl comply wiml emelt pravlsions or this permit n[oil be domed revoked. WATBR SERVICE!
G
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ 1"T PAID
_ '� IhcrebY affirm that them is acomwni0n lending agency lin the performance of D Reccipta
LUL p the work for which his perm,eesued(See.3097.Ci¢C.) 'I OTAL:
0 U L o"b,"Nana
Lenders Address "T(YTA L.
r G 1 ecnify that I have mad This upplicmion and slate that'he aMwe infemendem isIf BUILDING Hili
f' N onset l agreemcomply withal]city and county ordinances tool laws relating to QTY. MECHANICAL PERMIT FEE SEISMIC FEE
U z building construction,and hereby authml<e reprewntatives ofthiscity menlerupnt the
abovo lnceioned preps,ny for inspection purpnsu. t:1
UANCIiEGTRIC F[E(We)Igr m save,idenlnlly and keep ham,[sex the Cityol'Ciaertim,against ninminlies.judgmcto,swl,and expense,whichmay in any way a¢me against midCity DD'IO MECfL PLUMBING PHISsequence of he groming of this permit.
APPLICANT ON DERS'rANDS ANI)WILL COMPLY WITH AL1,NON-POINT ING UNIT(TO I ON 1 MSCI AN[CAL ITE
SOURCE REGULNI IONS,
ING U N IT(DVER I(tsm CPM) J CONSTRUC'T'ION TAX
SignatummApplirmidContndnr Date OOD(W/DUCT'•IIr Ur HOUSING MIT'IGA'TION FEE
HAZARDOUS MATERIALS DISCLOSUREWill the applicant or future building occupant.store m image haaarJous material NIT(TO 100.(00 BT U]
its defined by the Cupertlna Municipal Code,Chaper,9.12,and me Health and Safety
Code.Seclion 25532111)! IEAI'ING UNIT'(OVER 100 001110 U)
Wes E3 No VWl ILATION RAN(SINGLE RIiSID) PAID
Dae Receipt a
Will the app]cart or furore building he Huseequipmentordevicewhich HAILER-COMP(3HPOR 100.000BTU) V -
it hxr.:rdnu.,air mm�:Gminnna as AetineJ by by tM Buy Area Air Quality Management 1111AL
�ueoicl2 RUILER-COMP(OVER I00,00f,BTU)
❑Yes Fl No
I have read the havanlous mlim-11 requitement,under Chapter 6,95 of the Cali- AIRCONDHIONER ISSUANCE DATE
remit,Hot&Sum,y Code,Sections 25505,25533;rad 25534.1 understand that If Ibe NEW RESIDE TIAL MECH. SQ.FL
bedfngduu oat courenlly bavcamnea,'to,'fenny espunsduldy Inramify rhe ocenpunt �� �.Q
no thernqui mwnwbidt at m
rms,ber met prinis. nec of Cetill II Ocepuncy.
Owner or auhodmd agent Date TGIAL:l I ISSUED BY:
OFFICE
&�Cit.v
10300 Torre Avenue
Cupertino, CA 95014
of
Clpeitilio Buildin- Division
(408)777-3228
(408) 777-3333 (fax)
February 9, 1999
Homeowner
22370 Palm Avenue
Cupertino, CA 95014
SUBJECT: Permit#S 1887
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 CUPERTINO
Christy Akatiff, Administrative Clerk
Primed on Recycled Paper