30630 APPLI$,ANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLYsw
CITY OF CUPERTINO FURL.DING-ELECTRICAL 'PERMIT NO. 3 O k/��V^(J O
BUILDING DIVISION APPLICATIONIPF,RMITPLUMBING-MECHANICAL
IIUILIIING PROJECT IDEM'IFICATION
BUILpING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
06! u Qi We bre_ q�
NHR:S NAME: PHONE: COMRACTORSNAME: LIC NO:
!— 91> Z COyyQOLp
HC TECfI:NGINEIiR: - LIC NO: ADDRESS: 0 /`yJ�]`
CONTACT. PHONE: BUILDING P MIT INFO
0 Consultant Fees Paid by Applicant(Initial) - BL G ELF.c'T PLUME MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE L�-lt: hY¢�y�
1 hereby of rte that Item licensed under previsions of Chapter 9(commencing B ESC ION
044Z with Section cfDivisinn 3 of Nc Business and Procntions Codgamd my license is RESIDENTI
00 in full force and cHcct, PERMIT ISSUANCE
�Ul- License Class Lie,0 ❑SFDWL ❑KITCHEN REMODEL
F� Duro Canvaanr APPLIANCES-RESIDENT[AL
❑ADDITID ❑PLUMBING
RE-PIPIT
(Nf-..py ARC] I'HECT'S DECLARATION PANELS - ❑MU NIT, (]STRUCTURAL
Z p Z I understand my plans shall to used as public records MODIFICATION
—2140 UP TO]Oft AMPS
INTERIOR IMNIC REPAIR
�4 Licensed Pndessionnl 201-Ifxx1AMPS IMPROVEMENT
�ld � OWNER-BUILDER DECLARATION OVER IOf10AMPS ❑BATH REMODELJRIiPAIR' DEM TION
y X st 1 hereby,affirm that I am exempt from the Contractor's License Law for the
x 31 F following mann.(Section 7031.5,nosiness and Professions Co :deAny city or county SIGNS ELECTRICAL ❑OTHER
V7 ¢. wldch reg.(.,a permit to construct.alter.improve,domnurh,or repair any structure
�40 prior to its issuance,also requires the applicant lin such permit to file a signed statement SPECIAL CIRCUIT/MISC.
Nk
p. That he is limned p...anuo Ne pmvimme,mfthe Contractor's License law(C1mpmr9
aOC (commencing with Section 700[bo(Division 3 oflhe Bronessand Phaessions Cramor TEMP.MEI'ERORPOL INST. omm
6 n oC that he is exempt therefrom and the basis for the alleged exemption.Any violation ofmo ❑NEW BhDGI (TION ❑DEMOLITION
-,m SnOinn]I131.3 by any applicant torn permitsuhjeam
subjects npplicanmacivil penalty of POWER DEVICES ❑TENANT El FOOD SERVICESERVICEnot re than five hundred oOliars(5500).
ZG (]I,as owner of the property.or my employees with wages as their sole compensation, SWIMMING POOL tLECTRIC
will do the work,and the.structure is not intended oroffened for sale(Sec.7044,Business ❑IMPROVEMENTOTHER
R and Professions Cole:'[he Contractors License Law ones at apply to an owner of OU]'LETS-SW CHES-ITXO'URES
property,who builds or improves(hereon,and who oe such work himself or, tough
his own employees,prnvidcd that such impmvemen.s an intended or of d for NEW RF,SID PIAL ELECIE - SQ Ff.
sadaIf,howavo,the hullding m improvement is sold witra one yearofwmpletion,the SQ.FT..FLOOR AREA $/SQ.FT
er-1odhkr will have the burden of proving that he did nn ild or Improve for pur-
pose of sale.).
❑1,az owner of the property,am exclusively comrecting wird licero cmntmmrrs to AI-: PAID p
construct the project(Sec.Au4,Business and Professions C:sJcp The Co 'tar's Li-
r
i- r Ie�
rse Law does not apply to an owner of property who huilds orimproves there and Q'I'Y. PLUMBING PER FEE
who contracts forsuch pmjccls wird ecommands)licensed Pursuannnthe Commnr �i'T 7 1996
License Law. - P MIT ISSUANCE
❑ lam exempt sent rSec. ,R&P C for thixrenson ,\
��Owner - Date - R7bl -DRAIN&VENT-WATER(EA IJf I; ON
WORKER'S COMPENSATION DECLARATION BACK PROTECT.DEV
00th, by affirm under penalty of perjury one of the following declarations:
F1I have and will maintain a Certificate of Consent to self-insurcfer Workers Camper- DRAINS-FLOG OP,ANEA.GDND' y S 'TYPE CONSTRUCTION
cation,as provided for by Section 3700 of the Under Code.for the perfomance of the
work for which this Permit is issued. FIXTURES-PER TRAP
I have:tod will maintain Worker's Compensation Insurance,az regnircJ by Scaian
37M of the Lu&r Code,lnor he performance of the work for which Nispermit is issued. GAS-EA.SYSTEM-I INE 40 S
My Worker's Compensation Insurance ri
turner and Policy number are: OCC.GROUP ANN
I Cortico Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF IiXEMP HON FROM WORKERS'
COMP17NSATION INSURANCE GREASIVANDUSTRL WASTE INTERCPI'MR
(Nis action neednot be emaidesed ifthe permit is forma,hundred dollars(SIM) - BU NI O PL'Ii5
nr less) GREASE'I'RAP PLANCHF.CK7t co
Loy any thatixe Ne any armineenf Newmk for which Nis the W.kers.0 nFer- SEWER-SANITARY-STOR M EA.21X1 IT.
not employ my person in any manner so as to become snhject m the Wnrkern'Cnmpcm- E Y PE13
,� Applicant
nt of Califomie.Data
� APPlicanl WATGIt HEATER W/VENT/ELECTR GRADIN I.
In NOTICE TO APPLICANT:If,after making this Ceri ficam of Exemption,you should WATI7R SYSMMaREATING
hecome suhj,m to the Worker's Compensation provlsm,,of the Labor Code,you most SOILS F
forthavuh comply with such Provisions or Nis pernil shall he deemed revoked. WATER SERVICE
� zCONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMIi. SQ.FT. PAID
V Q I far
rte then there is.
sued( ecd3097.lending agency fonhc performance of Du Rucciptq
U. 1~^ the work fm which this permit is issued(Sec.31H],Civ.C.)
Q U Lendds Nanta TOTAL:
W Lender's Address - TOTAL:
�' Iy I certify that have read this application send state that N,n&ve Information is M
9P,
N correct.l agree to empty with all city and county ordinances and state laws relating to Q--Y. MECHANICAL PERMIT FEE
U building construction,and hereby authorize representatives ofthis city to enter upon the E
above-mentioned property for inspection purposes.
(We)agree to save,indenmi IF and keep harmless i,City of Cupertino against PERM]F ISSUANCE FEE
liabilities,judgmena.cons and expenses which may in any way accrue against said City ALTER ORADD TO MECH.
in consequence of the gmming of this permit. FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO HI,M)CFM)
SOURCE REGULATIONS. - AL FEE
AIR HANDLING UNIT(OVER 10,00(1 CFM) I'IONTAXSigature OfAp,lier.VCmmrvtnr Dmc EXHAUST HOOD(W/DUCT) MITIGATION FEEHAZARDOUS MATERIALS DISCLOSURE
Willthe applicant or future building occupant store or handle haiardOU5 material HEATING UNIT fro 100,000ItTHU
as defined by the Cupertino Municipal Cram.Chapter 9.12,and the Health and SafetyCode,Section 25532(x)'! HEATING UNIT(OVER ITOXCO BTU)
❑Y. ❑NO VENTILATION FAN(SINGLE RFSID)
Uma Receipt M
Will the applicant or furore building by the Bt use equipment or devices which BOILER-COMP 3HP OR 100.000 BTU
emit District?
us air nnuaminant.s its defined by the Bay Area Air Quality Management ( )
Oistrlct] 70 TAL:
[3 yes ❑No BOILER-COMP(OVER IIX1,000 BTU)
I have read the hazardous materials requiremene order Chapter l95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Code,Sections 25505,25533 and 25534.I understand that if the NEW RESIDEM'IAI.MF.CII. SQ.FT.
building does not currently have a tenant,that it is my responsiblliy mushily the occupant
of the requirements which must he met prior to issuance oft Certificate of Occupancy.
Owner or authonud agent Data TOTAL-: ISSUED BY:1
__ OFFICE
10300 Torre Avenue
(a 1, Cupertino,CA 95014
C-apertll10 Building Division
(408)777-3228
(408)777-3333 (fax)
May 14, 1997
Homeowner
20615 Rodrigues Avenue.
Cupertino, CA 95014
SUBJECT Permit 930630
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, the subject permit has not 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 permit card shows the final sign-off,
would you please contact us so we may complete our records?If the permit is not signed
off, 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 CUPERTNO
Christy Akatiff, Administrative Clerk
•
Priwou on Recycled Paver