B 0193APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITYQFCUPFRTINO INILDING- ELECTRICAL v PERMITNO, 01 JJ
PLUMBING - MECHANICAL.
BUILDING DIVISION APPLICATION/PERMIT s000i
I CL o 5' 17 ��
LICENSED CONTRA ECLAR OR'S DTION
I herby affirm That 1 out licensed under provisions of Chapter 9 (co nmencing
Z with Section 7") Division 3 more Business and Professions Cole, and my license is
Fin full Rte enrdc c!. __ �I4D,�b
U Licens C L-e� Lie.4RTrM
6 Dme Contractor r -f I �'sw
y ARCHITECTS DECLARATION
Z I understand or, Plans shall he used as Public record.,
Licensed Professional
•] OWNER -BUILDER DECLARATION
Q1 hereby ofiimt can I am cacmpt front ]he Courromon's Liceme Law for the
U Following mason. (Section 7031.5, Business and Professions Cade: Any cilyor county
ywhich requires a permit to construct. alter, improve, demolish, or repair any sfracture
prior to it i.saame, elso requires the applicant for ouch permit to file a signed omremm n
that he is liccwed pursuant to the previsions of the Contractors License Law (Chapmr 9
(commencing with Sec[im 7000) of Division 3 of the Business and Professions Cole) or
y ]last he is exempt horehound and the basis for the alleged! exemption, Any viohuion of
L� Section 7031.5 by any applicant far u permit subjects the applicants, o civil penallyof
11.1 some than five hundred dollars (5500).
O0 L as owner of the property or my employees with wages as [Mir Note compensation,
will do the work, and the swcture is not intended or offered for sale (See. 7041, Busi niss
m and Professions Code 'the Contractor's License, Law does not apply to an owner of
progeny who builds or improves thereon, and who does such work himself or through
hiswn employees, provider that such improvements are not intended or offered fir,
Nola IL however. the building or improvement is sold within one year of completion, the
owner -builder will have the burden of passing that he did not build or iso ur,
Anse of role.).
1, as owner of the property, am exclusively, contracting with Tic d emacha [o .'to
ennswct the project (See. 7614, Business and Professions CraleO Commences bill
cione Low does not apply to an owner of prupery who holds or isotin,u
who commas for such projects with o codruemr(M I uromm P, tract
t.lanse Law.
I am exempt under Sec. B &
.........
.............. (c X40 SSb
n _ NIC CONTROL
DDRESS: ❑
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial) BLDG ELECT PLUMB MECI
P ❑ ❑ L;?
TTY. ELECTRIC PERMIT FEE JOB DESCRIPTION
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL.
PANELS
UP TO 200 AMPS
2061000AMPS
OVER ]Bob AMPS
SIGNS ELECTRICAL.
SPECIAL CIRCUITIMISC.
TEMP. MITER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUT - S W ITCHES - FIXTURES
OFFICE
❑ KITCHEN REMODEL
ALTER - DRAIN & MINT- WATER (IIA)
❑ PLUMBING RE.PIPF
oner Date
❑STRUCTURAL
DISCLAMATION
Wm
SCOM I'BNrej.,
RACK PLOW PROTECT. IN 'VICE
C1 CHIMNEY REPAIR
under penally of perjury one of to following Jeclam'iom:
I hereby an&, on
0SWIMMING POOLS
❑ BATi RI:MODE1JREPAIR
will coo ficnte tose for Worker'scempnr
ono willfor
In.
DRAINS -11.00R. ROOF, AREA. GOND.
ofConsent
Labor Code. fort
ion, as provider for rm Sermon 3]1X1 of the Ichor CrWe, for performance of the
as by Section
rk for which This permit is issuer.
NIXTl1RE9 -PCN TRAP
11311offlas,
1have and will maimain Workers Compensation Insumance.whi h required by Seetinn
LnhorCnde, fnr the pertnrmmncu ofthe work (or which Ibis penni[is issnW,
GAS-EA.SYS'1'ISM-I INCA OIIITI:'I'S
GAS- F.A. SYSTEM OVER 4(EA)
IMPROVEMENT
Wnrk scam Insumn<ecaricrand PalicymSy'1efklkeCrl(C�i(6c)
rrier: n 0 ro .nn Policy Nn.: f/ �e-R 11
GREASFANDI15TR1, WASTE INTERCISPTOIt
C . TIFICATE )F E%F.MPI'ION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
(Thlssec[ion need not be completed tithe Permit is before hundred dollars ($ 00)
or less.)
SEWER - SANITARY - STORM EA.2 1
O z
O
h
PFT, i�
Da ry
Q
UO
Fthe
ILL
6s
.Fi fA
I certify shat in the performance of the work to this permit is issued, l shall
not c nplmy any person in tiny Inamor.m as ume Nabjea] to lite Workers' Conpa]-
action Laws of Calan ia. Dam
Applicant
NOTICES TO APPLICANT. If, after making this Caufcate of Exemption, You should
become subject to the Worker's Compensation provisions of the Labor Code, you muss
forthwith comply with such provisions or this permit shall be deemed revoker.
CONSTRUCTION LENDING AGENCY
l hereby affair that Nem is a conslmcIon lend," Y for the performance of
work for which this permit is issunl(Sec. 31X rv. C.)
Lcoftes Nome
WATER HEATER WNEM'/F.LECfR
WATER SYSTEM,71t LNG s
At
WATER SERVICE?
NEW RESIDRNTIALI'I N I - IQ 17 V
TOTAL:
Lender's Address
I certify Nm I have read [his npplicvtion and state that the above information is
correct. l agree to comply with all city and county ordinances and state laws relating to
QTY. MECHANICAL PERMIT
U
builiingconsuuctinmand berebynmhodmreprescntatim, obthiscily theme, ups,"Nc
SSUANCE(We,)
alawe-mentioned property for inspection purposes.
agree m save, indemnify and keep haemless Ne City of Cupertino against
ADDTO MIKE.
liablli[ics,judgment. costs andesperra. which my in any wayaccrue againstattiCityR
inconsequence oflie gmming ofthis Kraft.
APPLICANT UNDERS'T'ANDS AND WILL COMPLY WITH ALL NON-POINTDLING
UNIT( TO I(k000CFM)
SOURCE REGULATIONS.
DLING UNIT (OVISR IO,INq CFM)
URRAD
T 11001)(W/DUCDHAZARDOUS
Signature of Appliond/Cammmor Date
MATERIALS DISCLOSUREWill
the upplicam art furore builJing wcupvm stere m handle hazardousmvmriul
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(al]
O Yee IN.
UNIT ('1'D IINt,(XNI B'N)
UNIT (OVER 100,00013'1'U)
TION PAN (SINGLE RESID)
N511 the applicant or forum building occupant use equipment of devlCeS WhjCh
'tris hazardous air comnminsms as defined by the Bay Area Air Quality Management
BOILER -COMP TIRE OR 100.000 RTU)
BOILER -COMP (OVER 101 IKK) RTU)
.m co?
E]Yes Ifo
1 have reud the haanrlous concerns mouimmem[s under Chapter, 645 of the Cali.
AIR CONDITIONER
ty
NEW RESIDENTIAL MECH. SQ. Pr.
brmia Health&Safety Crile, Sections 25505,25533 and 25500. 1 mersmnd Not if the
baildingdaeN not camnllyhnve axon. that it is mryresph"sibilhy la nor ify['je cupant
r(f the rmWrenmms which mussYe rAcr mior ro issuance hf a Cenifn¢of W:uponcv
OFFICE
SQ. FT. FLOOR AREA
BUILDING DIVISION FEELS
PLANCIIECK PER
ENERGY FEL?
GRADING PRE
SOILS FEE
PAID
Mme i a
TO'T'AL:
BUILDING FEE
FEE? SEISMIC ME
ELECIRIC FTE
PLUMBING ITE
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION TE
PAID
Dme Rai #
TOTAL
ISSUANCE DATE
❑ KITCHEN REMODEL
�SFDWL
ADDITION
❑ PLUMBING RE.PIPF
❑MULTI.ONIT
❑STRUCTURAL
MODIFICATION
❑INTERIOR
C1 CHIMNEY REPAIR
IMEIROV17MENT
0SWIMMING POOLS
❑ BATi RI:MODE1JREPAIR
❑DEMOLITION
O OTHER
COMMERCIAL
❑ NEW BLDG/ADDI'T'ION
❑ DEMOLITION
O TENANT
EI FOOD SERVICES
IMPROVEMENT
❑ OTHER
SQ. FT. FLOOR AREA
BUILDING DIVISION FEELS
PLANCIIECK PER
ENERGY FEL?
GRADING PRE
SOILS FEE
PAID
Mme i a
TO'T'AL:
BUILDING FEE
FEE? SEISMIC ME
ELECIRIC FTE
PLUMBING ITE
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION TE
PAID
Dme Rai #
TOTAL
ISSUANCE DATE
10300 Torre Avenue
Cupertino, CA 95014
of
Cupertuio Building Division
(408) 777-3333 (fax)
s
February 9, 1999
Homeowner
22806 Poplar Grove Sq
Cupertino, CA 95014
SUBJECT: Permit #B0193
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
Printed on Recycled Paper