30918 ARPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALLPOINT PEN ONLY
F"U,
TY OF CUPERTINO BUILDING-ELECTRICAL � PERMITNO. rjO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J
]BUILDING PROJECT IDRNTIFICA'1'ION
ILpING dDDRfSS: �0 I(I!/'L,--�/��1 z yy+�rypA/M�E/ {,/!� ! SANITARY NO. APPLICATION SUBMITTAL DAT[
O / vn /— , 0LL4 ` {�/\IONP q _ RA dl�V I`
Y N/C C NfRO1.M
HITECT/ENGINEER: LIC NO: AI SS�vv_
/If/ f♦ 0 � '/ I ❑
CONTACT. PHONE: /�vv_ o 'F1YY(/ 41 BUILDING PERMITINFO
❑ Consultant Fees Paid.by Applicant(Initial) BLDG ELECT PULMO MECH
❑ ❑ ❑
LICENSED CONTRACTOR uadc,SocomecAT10N QTY ELECTRIC PERMIT FEE
I herehy afllrm nm I am IicenuJ under pmvisiom of Chapter 9(commencing JOB DESCRIPTION
,O,+a x with Sected 7000)"I D: 'ion 3,Into l3ooness and i' �fessinn Code, ad i y license i>
FOO in full force and effect y PERMIT ISSUANCE
�UU Licell .11 .N IW / L KITCHEN RF:MODF.1.
N�W0. Dau Con APPLIANCES-RP_SIDEND IAL ❑ADDITION -❑PLUMBING RE-PIPE
z ODm AR HITECT'S DE .A TIO ❑MULTI-UNIT ❑STRUCTURAL
ta2 IunderslanJ my plans ahallMused as able records PANELS MODIFICATION
O z—O UP TO 200 AMPS
rant. LicersW Rnfcssional ❑INTERIOR .[I CHIMNEY REPAIR
�d OWNER-BUILDER DECLARATION 201-I(XIUAMPS IMPROVEMENT
{L K W 1 hereby affirm that I am exempt from the Commmm's Litems,Law for the OVER IIXO AMPS - ❑BATH REMODEUREPAIR (]DEMOLITIO
{wi�OyU following reason.(Section 1031.5,Business and Professions Cale:Any city or county SIGNS ELECfRICAI. OOT ��
wit W F which requires a permit,o construct,alter,b.pove,demelish,.r repair any srmcture /
prior,.its isommen,alm requites theapplicaat forsueM1 pe.hit1.fileasignedetmemcat SPECIALCIRCUIT/MISC. /
p�P that he is liccnaW pursuant to the provisions of the Contractor's License Law(Chapter 9
I+Ia00 (commencing with Section 7")of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST OMMFR ,1 "� �
that he is exempt therefrom and the basis for,he alleged exemption.Any violation of ❑NEW BLDG/ADDITION [I DEMOLITION
it Wry Seelinn]03L5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICES
u^i ,m are than five hundred dollars(E5Sb. All ❑TENANT ❑FOOD SERVICE
zQ (]I,nv owner of,he property,ornryemployeaswinwagesuxncirwlecompcnsaion, SWIMMING POOL.FLIMPROVEMENT
W willcic hewnrk.aaJdw,mucamentmintended...fact!forsale(Sce.7(yTh Business ❑OTNP,R
W and Professions Care:The Contrumar's License I,aw docs mm apply m on owner of OUTLETS-SWITC k -
0. .. p fferty who builds or improvex them,.,and who does arch work himself or through
his own employees,provided that such improvements are n.,mended or offered for NEW REST 1.%�XS
aele.IL howevtt,neb,ilding orimpmvcmem is sell winin one yearofcompinion,,M1c SQ,F..]'LMR AREA SISQ,17.
mer-builder will have the burden of moving that he did not build or improve for put,
tuna of role.).
❑1,as construct the project othe Sm.704, n exclusively contacting with Beamed noracttora i- 'TOTAL:
eLatheesntpx.oad Businessand
rtyProfessions
obui Co or ini,eContractor's nd
.h.comwdces notapplymao with
acowner 'propery whored IForimpto the
Crioncmancon,er' H PERMIT FEE
License Lew. suchpnijcas with attmtnamr(OlicensW munuum mthc CnnOmm�r's
Fl Iam Law. MITIS ANCE
❑lam exempt under Sec. ,B&PCfonhis,reason
LTE &VENT-WATER(EA)
Doc "O 1 'VALUATION
WORKER'S COMPENSATION DECLARATION i PLOW PROTECT.DEVICE Pk
wncr I hereby affirm under penalty of perjury one of the following dialmmions:
IT have and will molmmn a Cert ifiwm.f Consent mwh-insure for Workers Camper. DRAINS-FLOOR,ROOF.AREA,COND.
labor,as provided for by Section 3100 of he Lobar Cod 'TYPE CONSTRUCTIONe,for the performance of the Y
work ho which this permit N issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,as requited by Section
3900 of the Labor Code,for the perfmmance ofthe work for which this permit is issuW. GAS-EA.SYSTEM-]INC,4OUTLETS
My W.r m ansa' n ur Ice d Policy um OCC.GROUP APN
Cartier: Policy No.: GAS-EA.SYSTEM OVER (EA)
.R77 OF :(EMPl ION FROM WORKERS'
COMPI?NSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTION
(9Llssection rollout herompinediOlm t is forone formal dollun(Stop, - BUILDING DIVISION FI7M
panni GREASE TRAP
or less.) PLANCHECK PEE
Loy any nutinthe pefforanymnnerince aOs tohe orkbac for whisubject
to permido
ikeri' ompnll 8HOVER-SANITARY-STORM BA.200 FEE
not employ any person in any manner an az m became suhjm o the Workeri Compcn-Applicant
.ENERGY FEE
Oz ALows,of CaliL+mia.Date WATER HEATER WNT/
ENF.LECTR
O Applicant GRADING FEE
tiNOTICE TObj APPLICANT:If,after ranking this Ccnonsof of(Labor Cod you should WATER SYSTEM/1'REATING
a , Iccome subject y the Workers Compensation permit steal of the cleared
Code,you must SOILS FEL!
CL7 forthwith comply wird such provisions or permit shall be damW revoked, WATER SERV ICE
Q
UO CONSTRUCTION i Ca construction
LENDING AGENCY NEW RFSIDEM'IALPLMB. SQ.FT_ PAID'
Ihereby whichaffirm this there i.swroal Sect ion len ding agency for the merfonnanceof Uma Rc ' tp
� — are work for which thispermitisissuW(Sec.3097,Civ.C.)
0 Lenders,Name TGTAL:
U Lenders AJdrens TOTAL:
WM 1 certify that 1 have mad this application and state shot To above information is BUILDING FEE
rn comet 1 agree m comply win all city and county ordinances and sate laws«luting to Q Y. MECHANICAL PERMIT FEE
U Z building construction.and hereby aunorize representatives(if his city to enter floods, SEISMIC PER
above-mentionW properly for inspection purposes. /^ _
(We)state to save,indemnify and keep harmless the City of Coolant,a gain. PERMITISSUANCE ELECTRIC PEE
Iiabillties,jmdgmeas,cos,sandexmenseswhlchmayin,nywayaccme against said City ALTER OR ADD TO MF.CII.
I'D—
in consequence of the gaming of this permit. PLUMBING FEE -'
APPLICANT UNDERSTANDS AND WILL COMPLY WITH qLl.NON-POINT AIR HANDLING UNIT(1'0 IO,1X0 CIONE O
SOURCE REGULATIONS. MECHANICAL 17FE
AIR HANDLING UNIT(OVER 1L0XCFM) CONSTRULTIONT X
Signammof Applicaut/C.naactor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION .E
^ HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building,ccupant sore or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health anti Safety
Colic,Section 2553260? HEATING UNIT(OVER 100.000 BTU)
E]Yes 0 N - VEN'I'ILAT10N PAN(SINGLE RESID) PAID
Date Receipt p
W d the applicantcontaminants
a refined by me Bt use c0,Air ent or Qualo,Managemces ent BOILER-COMP(3HP OR 100,100 BTU)
hazardous air com,minems as define)by the Ray Arca Air Quality Muna�emem O
strict? 'TOTAL:
❑yea ON. BOILER-COMP(OVER 100,(X10 BTU)
AIR CONDITIONER t ISSUANCE DATE
1 have read the hanmrdous maarl s reyuiremems unJer Chapter fi.95 nf,M10 Culi- 4
fo In&Safety Code.Sections 5505,25533 and 25534.1 understand out it the NEW RESIDENTIAL MECH. SQ.FC 2—
i
cee nn,curently have nt a ,mat it is my respmsibilitymnrnify the cecupmt
n hi prior,,issmnceofn C suten u1 AO
or cath TO
Doc TOTAL: ^
ISSUED BY: V
OFFICE
w.
•�,®:� 10300 Torre Avenue
Cupertino,CA 95014
Cii.c of
CLt*- er hiO Building Division
(408) 777-3333 (fax)
February 4, 1999
Homeowner � ..
1172 Scotland
Cupertino, CA 95014
SUBJECT: Permit# 30918
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
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