28888 FAPPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI'PY OF CUPF,RTINO BNLDING-RLECTRICAI. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT 'PLUMBING-MECHANICAL 28888
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OW "S NAME: � HON C RACTOR'S NAME: LICN NIC I CONTROLx
•ARCH TECTIENGINLER: E.1 p/ AU ESS: ❑
ONE
CONTACT, P' BUI ElConsultant Fees Paid by Applicant(Initial) BLDG ELECT PERMIT
FG
B ME H
r rau `-J 621, ED EJ El
LICIiNSEDCOM'RAC RO SI).CLARATION QTY. ELECTRIC PERMIT FEE
1 hereby ant rm atm E am licensed ander prescroux of chapter 9(enumerating JOB DESCRIPTION
aW d'Z with Smlion 900fry of Division3ofthe Business and Professions CWc.mgcny licenseis RESIDENTIAL,
F�� in full force aml eIf f�,/ PERMIT ISSUANCE —
e-u Licanm Class x—e•P-�^`��/j ❑SFDWL OKITCHEN REMODEL
�or -r-T.—T APPLIANCES-RESIDENTIAL ❑ADDITION MBING RE-PIPE
h66 Dam Can DECLARATION
ARCHITECTS DECLARATION DMULTLUNIT ❑STRUCTURAL
Z FO H Z 1 understand my plans shall be used as public records PANELS MODIFICATION
OZ�Q UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F,�L Y1 Licensed Professional 201-10(h)AMPS IMPROVEMENT
OWNER BUILDER DECLARATION OVER 1000AMPS D BATH REMODEUREPAIR 0DEMOLITION
C st I hereby affirm that I am exempt from the Contractors License Law roc the.
iq$O6 U following reason.(Section 9031 S,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W 3(L N whitb requires a pencil n,emcovcl,aIle,,amps se.de"utlixh.or repair any xtrvqure
�� prior to its issuance.also requires the applicant for such Permit file a signed statement SPECIAL CIRCUIT/MISC.
I!{} that he is licrnud pursuant to the provisions ofthe Convectors License Law(Chapter 9
..00 (c°mmencing wish Secti�n9011pd DivisionJof Ne Boniness and PrafessinnsCod,)or TEMP.METER OR POLE INST. COMMERCIAL:
d q thin he is caa"pt Ihcrcl'mnt and the ha,for the alleged exemption Any violation of D NEW BLDG/ADDITION D DEMOLITION
YX] Section IDJ l.5 by any applicant for a Permit subjects the applicant In a civil penally Lir POWER DEVICES
.y ❑TENANT ❑FOOD SIiNVICE
F Z>
not more that five hundred dollms(ESW).
wi Loshe work,the pmpetly.structure mycmntendes withwagesar alei(See 7ompemnion, SWIMMING POOL ELECTRIC OTHER G1ENT
y0 will do lesions and theheContractor's
is not Livens Law
Ramle(ply to an Business ❑OTHER
ly �
and Professions Code:The Commcnrzs Linnse Lew dtx.a not apply m an owner of OUTLETS-SWITCHES_FIXTURES
IS 3 property who builds or improves daemon,and who docs such work himself or through
his own employees,provided that such improvements art not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sole.IL however,the building orimprovemcul issold within one yeunt completion.lbe �s SQ.FI'.FLOORARPA E/SQ.IT.
trcr-builder will have the burden of proving that he did not build or improve for Pur- Isis iismer
Pae oLmle.). IYJT ,�:"-
1,as owner of the property,am exclusively contracting with licensed smi ractors to �11'
consumer the project(See,91144.Business and Professions Cade)Tho Convamer'I Li-
censeLaw does not apply In an owner of progeny,who builds or improves thencon.and QTY. PLUMBING PkM11' FEE
who contracts fur such projects with a contmamr(O licensed pursuant main Committers
License Law. PERMIT ISSUANCE
❑lton ext"rpt under Sec. T_.B&P C for do"r,..am x
ALTER-DRAIN&VENT-WATER(EA) /Do zz9"6W?g /,I. VALUA'LWd
O �) ORKLR'S COMPENSATION DEChARATION BACK FLOW PROTECT.DEVICE yy U V/'
I le
hcrcl frion under penalty of perjury one of the following declarations:
.D I have and will maintain a Cenilicate of Conscm to self-insure for Worker's Contpcn- DRAINS-FLOOR.ROOF.AREA.COND' STORIES TYPE CONSTRUC'T'ION
cation as provided for by Section 3700 of the labor Cale.for the Performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have nnU will intain Worke,'s Compensation Insarunce,as required by Scaiov
390 of the la e.'Plhe ltednrmance-!thew rk for rich this pemat e,issued. GAS-IiA.SYSTEM-]INC.40UILF:'1'S OCC GROUT' AI'N
My Werkcr's n lion Ins anccc rant licy ober art:
Comer: GAS-EA.SYSTEM-OVER J(EA)
CP,RTIPICAT.OF BXBMI'I'ON FROM WORKERS' -
MI'ENSATION INSURANCE GREASIIINDUS'I'B,WASTE INTERCBI'TOR
BUIL LING DIVISION FEES
fBtisses,,um eednalberme,lctcd ifthepermilisforotmhundreddolla (SIW) GRFASETRAY
of less) �yW y P NC �CKTEE
Q Applicant�///A P nes Lir as n come su 'cc u issued,l nhall -
Iccnilythe(in lhcperforinncc"f the work for which this permit is SE EA.210 FT. I
no,employ gnY in any l b bl a the Workers Compcn- ENERGY P:E
O �„➢/ WATER HEATER WNENT/ELEC IR GRADING -
z cation lawn of mi .
NOTICP.TO APPLE ANT:If,alter making(his Ccniliclh d-Excntplion,you should WAIHR SYS I'EM(TREATING SOILS PER
; becomeforthwithsuis- ,,i e Worker's Compensation provisions or the Labor Cale,you must
{SI fowith comply withsuch prevision.or this pencil shall be deemed revoked. WATI7R SERVICE
Q
7z Cl1NSTRUCfIONLENDING AGENCY NEW RESIDENTIALPLMD SQ.FT. PAID Date Receipt#
L)(:y Iherchy affirm that there is ucumry
construction lending agency Yonperformance of
the work for which this p—it is issued(Sec.309,Civ.C.)
u" F' Is"der's Name TOTAL:
V Le.dcru Address TOTAh:
lad BUILDING ITE
1 ecnify date 1 have read This application and one Ihm the above infannnion ix
IA e"rrect.I agree to comply with all city and county ordinances godson,laws relating to Q'T'Y MECHANICAL PERMIT FEE
L.7 Z building construction,and hereby authodserepresentatives ofthis city to enter upon the, SEISMIC FEE
above-mentioned p ureary for inspection purposes. PERMIT ISSUANCE
(We)agree Rt save,indemnily and keep harmless the City of Cupcni"o against ELECTRIC fgiE
liabilities,judg ))caste andcapcnus whichmay in any way ac<rvc egainn said City ALTERORADDTOMECH.
in conscqu, of7cgmnting of this pertnot. PLUMBING FEE
APPLICA U':" NDS AND WILL COMPLY WITHALLNON-POINT AIR I IANDLINGUNIT(TO 10,000CFM)
MECHANICAL FEE
SOURC GULATI
�- AIR HANDLING UNIT(OVER 10,000CIMD CONSTRUCTION TAX
1
Signatureu�plicant/Contmnm Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future buildingoccupa"t store or handle huzardeus material HF.AI'ING UNIT('PO 101000 BTU)
as deft"od by the Cupcnino Municipal Cade.Chapter 9.12,and the Healda and Safety
Code,Suction 25532(u)t HEATING UNIT(OVER 10"BTU)
D Yes ONO VENTILATION FAN(SINGLE RFSID) PAID
Data ReteiptM
Will the applicant or future building occupant use equipment or devices which
'mil h....dins air,onmminanla its defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 10.000 BTU)
TOTAL:
Ucut BOILER-COMP(OVER 10,00 BTU)
❑Yes DNo
AIR CONDITIONER
I have the hazndu e 2ras a s reyoiremtms nada Chapnd understand of the Cali- ISSUANCE DATE
rami.Heal afoy CM gcclians 25505,255JJ anJ 25534.1 undctsmnJ that if the NEW RESIDENTIAL MECH. SQ.FI'. xF/
building acumentl veam"n"l.do my respnnsibitay to notify the occupant
or the mems who must1, n 's officenif Lite cu
Owneror a m.N agent Date TOTAL: ISSUED BY'.
OFFICE
a® 10300 Torre Avenue
• Cupertino,CA 95014
Cil.v (d,
Cupp trio Building Division
(408)777-3228
(408)777-3333 (fax)
September 25, 1996
Donald Roseburg
8051 Park Villa Circle /
Cupertino, California 95014 \�1'
SUBJECT Waterheater, Permit#28888
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
Pnnmtl an RBGYGIPa Papw