31277I APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITV 11F Cl IPRRTINO - BUILDING - ELECTRICAL,
BUIUDING DIVISION APPLICATION/PERMIT
31277
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❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
❑ �` ❑ ❑
LICENSED F.DCONTRd mxbhSDECLAHf DECLARATION
1 M1ercM1y aflifm that inch licensed under provision n(Chupter 9 (commencing
with Sation]qXp ofDivisian3ofthe Business and Professions CnJe, and my licenm is
in full force and cR t. y _ 3
License lass LIC.M /I(.
Contractor
ARCHITECTSDEC RATION
1 understand my plans shall he used as public records
QTY. ELECTRIC PERMIT PF.E
JOB DESCRIPTION
RESIDENTIAL:
I] SFDWL ❑ KITCHEN REMODEL
❑ADDITION C1 PLUMBING RE -PIPE
El MULTI ❑STRUCTURAL
MODIFICATION
[:1 INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEL/REPAIR ❑ DEMOLITION
El OTHER
PERMIT ISSUANCE
APPLIANCES
PANELS
UPT02MAMPS
LicensW Professional
Oat I am exempt from DECLARATION
o for the
1 herthy u(Srm that 1 am esempt from the Cosants C a License city
followingreason.(Section IDSLr Businessandmpr Professions Ca lc: Any city or county
repair any atemure
which rcyuircs a permit e, also re conswe, aaee improve, demolish, file
thprintt he its cense pursuanttheres the
ovisio so for such permit License Law
that he is licensed pursuvm to the provisions of the Comracmr'x License haw (Chnpmr 9
(commencing with Section 70(y) of Division 3 of the Business and Professions Codc)or
that he is exempt Nen from uad the basis for the alleged cacmptiam. Any vimlmim of
Section 7031.5 by any applicant for a permit subjects thea,br.m In a civil penalty of
mora cum lova hundred tiollvrs y yin 1.
lifslonclnrmyemplended witbwned for sale
work,
dothework, Co the he Co eienot intended Law redfor sale(See.t Il an. Business
prop Profession Code: The Contraem's License Law dons not apply s if owner of
hpropertyis own who builds or improves thereon, and who dos such work himself or through
his own employees, provided that such improvements me not intended or offered! for
sale, If, huwevee the building or improvement is sold within oneycarefcampinionJhe
owner -builder will have the burden of proving that he did oat build orimpice for par-
pose of sale.).
C] 1. as owner of the property, am exclusively connecting with licensed comments; to
common the Project (Sce. ]034, Business and Professions Code:) The Conuactoh Li-
cerise law does not apply to un owner ofpropeny who builds or improves thereon,and
whocmnmctx forsuch pmjectswithacontractads) licensed pursuant m the Contractor's
F-1 ense lam
❑ I am caenpt under Sec. , B & P C fonhis mann
201-1000AMPS
OVER 1000 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
_
COMMERCIAL:
NEW BLDG/ADDITION ❑ DEMOLITION
TENANT ❑ FOOD SERVICEm
❑
IMPROVI:MENT
DOPIER
POWER DEVICES
SWIMMING POOLELIiCI'RIC
OUTLETS-SWITCf{FS- FIXTURES
NEW yi'FiGb1YWili! F.LECTR
/�sss�a ww
�Y {' �
SQ. PI'. FLOOR AREA
�i p
a'1 B
�� Y
�//
C -` 0 �
ESQ. FT.
QTY PLUMBING PERMIT FEE
-
PERMITISSUANCE
ALTER -DRAIN&VENT-WATF.R(EA)
One
L1yr VALVA N
rKl/flu
I hereb uflirmRKFR'S COMPENSATION DECLARA'I'ION
y penalty o perjury one of the followingdeclarations
I haveund will mai main a Certificate of Consent m self -insure for Worker's Comport.
ion, ax provided for by 9ation 3]110 of the Labor Cale, for the pcdinmmoa of the
-wnrk for which this permit is named.
'I] 1 have and will maintain Worker's Compensation Insurance, as required by Section
3700 ofthe Lahor Code. for the performance route work for which this permit is issued.
y Warke' Ca ^�pensvtion insanes carie, and P licy ryup
Cnreicr. �jpr^r Pabcy Na.:,` 8�° —9y
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
f11issation need nm becompleted ifnhe perrnin is frame hundred sholurs(SIM)
or less) Lcertify that it the performanceofthe took for which issued.shall
not employ my prison in anymanner so assm become subject to the Wnrkets'Compoo.
satin. Lawsof California. Data
Applicant
BACK FLOW PROTECT. DEVICE
DRAINS -FLOOR, ROOF AREA, GOND.
STORIES
(ICC. GROUP
TYPE CONSTRUCTION
APN
FIXTURE
GAS - EA.
GAS -EA. YST ER A
GREASEBNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION LEES
GREASETRAY
PLANCHECK FEE
SEWER -SANRARY-STORM EA. FT�
ENERGY FEE
WATER HEATER WNENUE-LECTR
GRADING ME
NOTICE TO APPLICANT. If. after making this Certificate of Exemption, you should
subject to the Workers Compensation provisions of the Latin Code, you must
Rolocith comply with such provisions or this permit shall be theme it menace.
CONSTRUCTION LENDING AGENCY
I hereby affirm that hem is a construction leading agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's N.nte
Lender's Address
I certify that I have rend Nis application and suite that the above information is
correct l Agra In comply with all city and county ordinances and state laws relating to
building construction, nndherebymaxonceir msenuitives .176, city fees a,.,nthe
monecmemioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
Iiabiloies,judgmenu, costs and expenses which may in any way smote against said City
in .sequence of the gaming of Nis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
�/i
/
WATER SYSTEMOREATING
WATER SERVICE
SOILS FEE
PAID
Uate
eceiptp
NEW RESIDENTIAL PLMII. SQ. FT.
Nis, TOTAL:
TOTAL:
BUILDING FE
QTY, MECHANICAL PERMIT FEE
SEISMIC FE
ELELT iG
PERMIT ISSUANCE
ALTERORADDTOMECH.
PLUMBI 'FEE
AIR HANDLING UNIT (TO Iff" CFM)
MECHANIC A FEE
AIR HANDLING UNIT (OVER I).CFM)/A4f
CONSTRU ION TAX
Signaturenl plicanUComfacmr
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hnarJous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Iicuhh and Safety
Calc, Sectinn 25532(.)7
❑Yes, 0 N
building occupant use
Will the air contamiof nants as
haanrdous air amaminants es defined by the Buy Amu Air Quality Management
ce Air ent Qurrdevices Manaement
soon I
C]Yes 0 N
1 have rend the hzaardmis materialsAIR
requiremema under Chapter 6.95 of the Cdi-
forms Health & Safety Code, Sections 25505.25533 vol 25534. 1 understand that if the
buildingdoes not currently have o tenant, Nm it is my respenihility to notify Ne occupant
of the requitame.tu which must be met prior to lactone, of v Ccnifieme of Qcupancy.
EXHAUST HOOD(W/DUC17
HDUSIN MITIGATION FEE
HEATING UNIT (10 100,00a, 131 U)
HEATING UNIT(OVIiR 100.,X1 BTU)
PAID
Use Raeiptp
VENTILATION PAN (SINGLE RF.SID)
BOILER- COMP(3HP OR 100.0(X) BTU)
TOTAL:
BOILER -COMP (OVER 100.001) BTU)
CONDITIONER
ISSUANCE DATE
ISSUED BY:
NEW RESIDENTIAL MF.CH. SQ. FT.
Owner or and n otal agent Data
TOTAL:
OFFICE
Of,
10300 Torre Avenue
Cupertino, CA 95014
0 Building Division
y (408)777-3228
(408)777-3333 (fax)
June 18, 1997
Business Owner
19863 Portal Plaza
Cupertino, CA 95014
SUBJECT Permit #30768
Dear Business Owner:
We have been going through our files in the Building Department, and contacting those
people with permits remaining "open.
• According to our inspection records, the subject permit has not had a final inspection.
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 dispose of the file and remove the records from our computer.
Thank you for your assistance.
Sincerely,
CITY OF CUPERTINO
Christy Akatiff, Administrative Clerk
Prinren on Pecyded Paper