29490APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
OFFICE
CITY OF CUPERTINO BUILDING - ELECTRICAL.
BUILDING DIVISION APPLICATIONFPERMIT PLUMBING - MECHANICAL.
_ WILDING PR(LIEer FBENTIFICNPION
PERMIT
L MV 4 VJ NO. /1 /� 4 /\ 0
BUILDINGADDRL.SS:
I o.2y 0 Des,
SANITARY NO.
APPLICATION SUBMITTAL DATE
OWNER'S NAME: PIIONE:
CONTRACI OR's NAME: LIC NO:
N/C^-
El _T
CCOONTRR�OL g
CARCUITE
ENGINEER: LIC NO:
ADDRESS:
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ONTACT.PHONP.:
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT (INFO
BrrL]DDt�fG ELECT PLUMB MECH
,LT ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that 1 mo licensed under Provisions of Chapter 9 (commencing
with Scarce ndefe(Division3of the Business and Professions Code. anJm license is
� y
full and effect.
License Class Contractor—
Dose Commctrar _
ARCHITECTS DECLARATION
Iunderstandm I
y p ons shall M used m public records
QTY EL17CTRIC PERMIT FEE
-
JOB' DESCRIPTION
RESIDENTIAL:
❑SFDWL ❑ KITCHEN REMODEL
[]ADDITION C1 PLUMBING RE -PIPE
❑MULTI -UNIT C3 STRUCTURAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEUREPAIR 0DEMOLI�j{,{/�Q�tN�i�{(�%j
❑ OTHER
9
PERMITISSUANCE
APPLIANCES - RESIDENTIAL
- -
PANELS
UP TO 2110 AMPS
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby . (Sect that 1 em exempt from the Contractor's License Law for the
lMlnwing reason. (Section 7031.5. Business and Professions Coda: Any city m county
which requires a Permit to construct. dm. improve, demolish, or repair any naucmre
prior to its issuance. also requires the applicant fur such Permit to file a signed statement
that he is licensed pursuant to the provisions oflhe Contractor's License latw(Chapter 9
(commencing with Section 10001 of Division 3 ofthe Busierssand Professions all I
mat he is exempt therefrom and the basis for the alleged exemption. Any violation of
S«tion 1031.5 by ony applicam for o permit rubj«¢ Ne apti icamno a civil Penalty of
not muse than rise hurdled dollarsyempl.
❑ ProPe Y YemP Y 6compression,
lar' she norm employees wishwa wages lale(S .
Lo me
will d. Professions
sions still the Tin, on a not intended License few rsed does not apply to on, Business
Code: imp oyes thetreos License I do dos not apply s if owner of
and ray who
his own who builds or improves thereon, and who does such work himself or through
his own employees, provided that such imp{nvemen¢ are not intended or n0ered fur
sule.If. how,ver, the hnilding nr imprravetrmm is sold within one yam of romPletinn.theLL
ownerbuilder will havemebuNennf proving that hedidnnt builderimprove
torpor -1, as owner of the property, am exclusively contracting with licensed contractors to
conslmcl she project (Sec 7044, Business and Profossions C(xlo) The Cntnmcmr'e Li.
cense Law does not apply to an nm
wneoof progeny who builds or improves thcrn.and
who contracts for such projects with o conuscrorts) licensed planning to the Conhtator's
License La,
❑ lam exempt traders , B & P C for this ream.
201-1030AMPS
OVER l"AMPS
SIGNS ELECTRICAL.
�Eq
SPECIAL CISCO PUMISC.
-
Ar'fr)
-IVY_'
TE MP. METER UR FO LE INST.
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES -FIX'I'URFS 'J
NEW RESIDENTIAL CPR SQ FT.
0RARIiA
M, 2 51996
/" \l. Vur s -fn 11VV
Is
$/SQ, Fr'.
TOTAL:
QTY PLUMBINGPER IT FEE
PERMIT ISSUANCE
At VIER
Owner s Dom
VO CER3 ?15siffiWATION DECLARATION
I hereby affirm under Penalty of perjury one of tM following declarations:
I have and will maintain a Certificate of Consnt mself insum(or Worker's Compact.
Linn, as provided or by Section 3913 ifthe Lamm Code, fur the perfnrmmree iA the
lark far which this pemit is issued
❑ 1 have and will rommmin Worker's Compensation Insurance, as requited by Section
37M of me Labor Cole, for the Programmatic of the work for which this permit is finance.
My Worker's Compensation Insumncr carrier and Policy number are:
Carrie; ]',,lily No.:
CERTIFICATE UP EXEMPTION MOM WORKERS'
COMPENSATION INSURANCE
(This section need not becomPleted ifthe permit is fora., hundred ddlan($ 1(0)
or less.)
Icertitythul in the performance,,(roc work for which this permit is issued, l shall
nut employ any person in any manner u as to become subject to me Workers' Coope
an.. Laws of Calif imis. Dam
Applicant
VALUATION
fa,
C/
BACK ROW PROTECT. DEVICE
DRAINS -FLOOR. ABPA, GOND.
ST. 'S
OCC.GROUP
P 'F CONSTRUCTION
APN
FIXTURES -PER TRAP
GAS - f- . SYSTEM I INC. 4 OUTLETS
GAS -IIA. SYS'I IN -OVER 4 (BA)
GRL'ASMNDUS1'RI. WASTE. INTERCEPTOR
BUILDING DIVISION F' S
GREASETRAP
PLANCHECK FEE
SEWER -SANITARY -STORM BA.200 Fr'.
WATER HEATER WNENTMLECTR
GRADING FEE
NOTICE TO APPLICANT: IL afar making this Cenificum of Exemptimt, you should
become subject to she Worker's Compensation pronsinnsof the Labor Cole, you most
forthwith comply with such provisions or this panto shall he deemed revoked.
PENDING AGENCY
Ihereby affirm that here is a consmtmion lending agency for the Performance of
the walk for which this Permit is issued(Sir, 3091. Civ. C.)
Lender's Name
Lender's Address
WpIBR SYSTEM/I'REAPING
WATER SERVICE
ti01L5 FEE
PAID
Dat. RcceiptN
NEW RESIDENTIAL PLMB. SQ. ITT.
TOTAL:
TOTAL:
I cenBy that I have read this application ..it slam that she above inf.nnmion is
correct. 1 agree m comply with all city and county ordinances unit state laws relating to
building construction, and hereby authorize representatives nfthis city to emerup.n me
above-mentioned property an inspection purposes.
(We) agree to save, indemnify and keep hemdess the City of Cupeninra against
lialolities,judgments, costs and expenses which may in any way accme against said City
in consequence of the g,.am, of this permit.
APPLICANT UNDERSTAN S ND WILL COMPLY WITH ALL NON -POINT
SOUR( :GUT. TIO - .
10"d it
Sign pph V u ,set ate
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building resonant or handle humorous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Coda, Sccsion 25532(.)1
E] No, ❑Nu
'
Widousll are air contaminants
future defineduilding by upant the Air Quality Macasement
- it hazardous air conaminants xs Defined by the Bey Area Air Quality Management 0 N
but?
❑Yes l
(have read the huardnux materials requirements Chapter 695 of the Cali-
fomia Hea0h& Safety Cosh, Sectilanx25505. 25533 and 25534. 1 understand mat if he
huilJing does no currently have o meant, mm it in.ry respnnsihillty m notify she rccupam
of the requirements which must be the pd., t. issuance of a Cenilicam of Occupancy.
QTY. MECHANICAL PERMIT FEE
BUILDING FEE �•
SEISMIC FEE
PERMIT ISSUANCE
LLECIRIC FEE
ALTER OR ADD ID MECH.
PLUMBING FEE'
AIR HANDLING UNIT (TO 10.00(1 CFM)
MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CPM)
CONSTRUCTIONTAX
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE
HEATING UNIT 00100,000 BTU)
IIBAT'INO UNIT (OVER Palatal BTI])
PAID
Data Receipt
VENTILATION PAN (SINGLE RESID)
BOILER- COMP(3Hit OR 100,000 BTU)
TOTAL:
BOILER- COME (OVER 100,000 W' U) '
AIR CONDITIONER
ISSUANCE DAT°
ISSUED BY:
NEW RESI DENTIA L. MECH. SQ. ITL.
Owner or eutbotised agent Ilam
TOTAL:
OFFICE
is
0
10300 Torre Avenue
Cupertino, CA 95014
Cupertino o Building Division
(408)777-3228
(408) 777-3333 (fax)
January 22, 1996
10240 Phar Lap Drive
Cupertino, California 95014
SUBJECT Permit: #29490
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
0