28471 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO.
.BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
28471
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
130 �_ 11 L �+� cr gSo1 49 . ^ S
OWNER'S NAME: PONT:PgQ{,2.2g CONTRACTOR'S NAME: . LIC NO:
yh 6 253 Go 115 NIC, CONTROL#
RCHITEOT/ENGINEP,R: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT lNFO
❑ Consultant Fees Paid by Applicant(Initial)• BLD, ELECT PLUMB MECH
UCENSEDCONTRACrOR'SDECLARATION QTY ELECTRIC PERMIT TEE ❑ ❑
I hereby affum Not I am llcemed under provisions of Chapter 9(carrommeirg JOB DESCRIPTION
aIL withSectinn]gyp nl'Divicion3nf the Husiness and Pr�fessi�nsCode,nnJ mylicenxc ie �
0 0 PERMIT ISSUANCE RESIDENTIAL:
n full force and effect.�U� License Class Conn ❑SFDWL ❑PLUMBIN RE-PIPE
� Dam Connector APPLIANCES—RFSIDENTIAI. ❑pDDIT10N El PLUMBING RE-PIPE
F7IL ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
ZOm'b IunJersmnJ my plum shall focused.,puhlio,mameds - MODIFICATION
O,'�-O UPTO2WAMPS TERIOR [I CHIMNEY REPAIR
r4T-- Licensed Professional 201-100DAMPS IMPROVEMENT
�y OWNER-BUILDER DECLARATION ConneON
y 6' 1 hereby affirm that 1 am exempt from the Commctnr's License Law for the OVER 1000 AMPS El BATH REMODEIJREPAIR [I DEMOLITION
)d O 0.V following reason.(Section]031 S,Business and Professors Cudu:Any city nr county SIGNS ELECTRICAL ❑OTHER �J�.�.�p
61 W w. which requires a permit m construct,alter,improve,demolish,or repair any structure � is-quA[�L.�
C-0 pronnitissuance.alsorequirestheapplicant for such prmittofile.simedsmtement SPECIALCIRCUITMISC, li•
Nat he is licensed pursuant to the provisions ofthe Contactors License law(Chapter 9
<0 (wmmrncing with Seation]OW7of DivisionJof the Broure, and Professions Coce)or TEMP.METIER OR POLE INST. COMMERCIAL:
L o y that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION .
{I• Section 7031.5 by any applicantfor it permit subjects the applicam to a civil Penalty of POWER DEVICES
Zy not mom than Eve hundred dollars($500). ❑TENANT ❑FOODSERVICE.
❑I,as owner of the norm to with woes as their sale cons nation, SWIMMING POK)L ELECTRIC" IMPROVINENT
property, Yemp yeedin g pe
will pr the work,and theno Com structure is nor s License
or a w does
i....a(Sect.m*. act oflie
❑OTHER
and professions Code:The Conwnnrs License l.aw Jces not apply m an owner of OUTLETS—SWITCHES-FIXTURES
propeny who builds or improves thereon,and who docs such work himself or through
his own employees,provided That such improvements am not intended or offered for NEW RESIDENTIAL ELECT 5 FT.
ale.If.however.The building or improvement is sold within one year ofcompletion,the SQ.FT.FLOIDRARFA VSQ.Er
owner-builder will have the burden o(powing that he did not build or improve for pur-
.00
Essentialist.
❑I.as owner of He propetty,ant exclusively cootraming with l use,,xlconm.cmrsm )T _
consumer He project(Sce.7094,Business and Prefeasians Code)The Comment',Li-
come,Law Dues of apply to..ownerofpropeny who hands.,improves thereon,and QTY, PLUMBING PERMIT FEE
who cmaracra for ouch projects with a emans chuhn licensed pursuant m the Commcmrs ,q
License Luw, PERMIT ISSUANCE
❑ lumexcaTm under site ,B&P C for thisrwsmi I ' y
Owner Dam ALTER—DRAIN&VENT—WATER(EA) ( VALUATION
WORKER'S COMPENSATION DECLARATION
I hereby atErm under h f BACK ROW PROTECT.DEVICE V pp
Penalty perjury one of the fallowing Jalmatirins: /`f 1rJ
❑I have and will maintain aCenilleate of Gmsennn selfinsume far Worker's Conium. DRAINS—FLOOR,ROOF,AREA,COND. RIES TYPE CONSTRUCTNUN
section,as provided for by Section 37N)m the Labor Code,for thepe,firom or,of the
work fer,which this pemit is issued. FI%YOKES b PERQRAP -
❑1 base and will maintain Workers Co nfameadon Insurance,as required by Section pp r
37Wof the LaborCodq for the performance ofthe work for which this permit is issued. GAS—EA.HMETEM55j gJ .4 OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number,ur<: ali
Cartier: Policy No.: GAS—EA.SYSTEM-OVER 4(EA)
CEU1171CATE OF EXEMPTION FROM WORKERS'
COMPIiNSATION INSURANCE GNEASMNDUS'TRL WASTE INTERCEPTOR BUILDING DIVISION FRES
(Thiesecrim nml not be completed if Ne permit is for one hundred do[].($1 W) GREASE TRAP
or less.) PLANCH_ECK FEE
I certify that in the performance ofthe work for which this permit is issued,l shall SEWER'—SANITARY—STONM EA.2W FT.not employ any Person in any msubject summer so as to become subjeco the workersCompen- ENERGY FEL'
,z .tion Laws of California.Dam WATER HEATER WNEM'IELECTR
�O Applicant - GRADING FEE
NOTICE TO APPLICANT:if,after making this Certificate of Exemption,yon should WATER SYSTENt"REATING
become subject to the Worker's Compensation prosisions'of the Labor Cade,you must _ SOILS FEE
aQ forthwith comply with such provisions or this Permit shall be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Pr. PAID
V O l hereby affirm that is a construction lending agency for the performance of 'Dae Rm .tX
w H the work for which this permit is Issued(Sec.3097,Civ.C.)
O Lenders Name - TOTAL:
{U lenders Address TOTAL:
P. 1 certify that I have read this application and state thanhe ah ere infommtion is BUILDING
V) correct 1 agree to comply with all city and county ordinances and stare laws relating to QTY MECHANICAL PERMIT PEE
V � building wnswnion,and hereby uwhnrize represenmtives of this city In crater upon the SETS P r '
above mentioned prolxmy for impcminn purposes.
(We)agree to save,indemnify and keep hamdcss the City of Cupertino against PERMIT ISSUANCE EL[ IC 811 s,_
liabilities,judgments,costs and expenses which may in any way accrue against aid City p1,TER OR ADD TO MECH. PLUMBING PEE
m consequence of rhe gmnfng of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI,NON-POINT AIR HANDLING IINIT(T(I IIpIX)CFMI MECHANICALPP.
SO C F.GULATIO
sa.
AIN HANDLINGUNIT(OVER Ig000CFM) CONSTRUCAL TAX
t gnavrm ofApplicanVContmctor Date EXHAUST HOOD(WIDUCI} DOUSING MITI,ATION FIT
MATERIALS DISCLOSURE
Will the applicant or furore building overlain store or harshe humorous material1113ATING ON]r(TO I(k1,110offI U)
m delined by The Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Code.Section 25532(a)? HEATING UNIT(OVER I W.00o HTO)
C]Ye' ' -7 No VENTILATION PAN(SINGLE R&SID), PAID
I
are
NecciptM
Will the applicam manta a defined by the nt Bay A equipmem or Quality
Macesnagement
nt BOILER—COMP OHP OR I W.0 BTU)
air haz.rdcos air contaminants as defined by the Bay Arca Air Quality Managcmcm 0 AL.
Disoict?
❑Yes ❑No BOILER—COMP(OVER I00,00313TU)
I have read the hazardous materials requirements under Chapter 6.95 of Nc Cali- Alit CONDITIONER
q P ISSUAN F,DATE
fomin Health A,Safety Code,Sections 8505,25533 and 25534.1 understand that if to NEW RESIDENTIAL MECH. SQ.FT.
building does nm currently have a tenant,that it is my responsibility to notify Bre occupant
of to requ oro mens which must be mer prior to issue=of a Cenifmam of Occupancy.
Owner or amhorised.,car Dam TOTAL: ISSUED BY:
OFFICE
0Ciof 10300 Torre Avenue
Cupertino,CA 95014
Cupertuio Building Division
1 (408)777-3228
(408)777-3333 (fax)
May 8, 1996
Homeowner
1306 S. Stelling Road
Cupertino, CA 95014
Re: Expired permit, (copy attached)
Dear Owner:
According to our records, the referenced permit has not been finaled by a City building
inspector.
A permit is considered to be valid only six months from its last inspection date. If your
• permit shows that the final inspection has been completed, please send a copy of the
permit along with this letter to: 10300 Torre avenue, Cupertino, CA 95014, attention:
Building Department.
If your permit has not been finaled,please contact the building department(408) 777-
3228, so we may arrange to extend your permit and schedule a final inspection.
The City of Cupertino requires a response within ten (10) working days from the date of
receipt of this letter. If we do not hear from you within this time, the building department
will have no other recourse but to resolve your permit as expired and discard the records.
Thank you for your cooperation,
Building Department Staff, City of Cupertino
Primed on Recycled Paper