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30471 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY I - (A I V OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL' a"F O A �� BUILDING'PROJECT IDENTIFICATION 4 ILDING ADDRESS: 3- SANITARY NO. APPLICATION SUBMITTAL DATE fte,v So LMA/ L ti FACT Q bio X16 'g NA PHONE: CON'BACTUR'S NAME: _ LIC NO: L N(C CONTROL g \ CHITEC/EfJ 1 EER: ,IC NO. ADDRESS: CONTACT: PHONE: BUILDING PERMIT INFO E] Consultant Fees Paid by Applicant(Initial) BLDG ELEU PLUMB MECH LICENSED CONTRACTOR'SDECLARATION I hereby affirm don I oro liremcd under provisions of Chamer9(commencing QTY ELECTRIC PERMIT FEE JOB DESCRIPTION ow aid Section]IXgp of DivisionJofthe Business enJ Pmfnsions Cade.wd mylianse is /� RESIDENTIALJO full farce and effect. PERMIT ISSUANCE �-7 c�Z License Class LIC.g ❑SFDWL - ❑KITCHEN REMODEL b60. Due Commctw APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE 1..7r>>n ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL Z O-q 1 understand my plans shall be used as public mcnNs O'x`G UP T02(I AMPS MODIFICATION ��ttssJ� Lmensed ProfmPOonN El INTERIOR ❑CHIMNEY REPAIR �YJ IMPROVEMENT J. OWNER-BUILDER DECLARATION 201.1000AMPS yy CC 6 1 hereby otTnn that 1 um exempt from the Contractor's License Law for the OVER 1000AMPS ❑BATH REMODEUREPAIR El DEMOLITION U fallowing remon.(Section](131.5,Business and Profeesinns Code:Any city or county SIGNS ELECTRICAL ❑OTHER tool WO which requires a Permit to consumer,alter,improve.demolish,or repair any xwcmrc priorm its ismmee,also requires the applicant for such p manum Ella signed statement SPECIALCIRCUIT/MISC. —�'• y that he is licensed Pumiom duan on the pvisofthe Cmareemex License Lowhapm (Cr9 ' q0 (commencing with Section AMO)ofDivision 3ofte Businessand lYofessiors Cuba)or TEMP.METER OR POLE IN,T. COMMFRC[AI• d y c that he is exempt therefrom and the basis fnr the alleged exemption Any virlium.of El NEW BLDG/ADDITION F4CI tL Section 7031.5 by any applicant a Permit subjects the ambulant to a civil penalty of ppWER DEVICES El DEMOLITION Z y not tome than five hundred dollars($500), ❑TENANT ❑FOOD SERVICE 0 ❑1,as owner ofthe Property,or my employees wit wages in their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT will do the work,and the structure is not intended or offered formic(Sol.7044,nosiness ❑OTHER and Professions Code:The Cont.&P License Law arms not apply to an owner of OUTLITS-SWITCHES-FIXTUR Prapeny who builds or improves thereon,and who does such work himself or rbmugh his own employees,previdai than such improvements me not intended or offered for NEW RESIDENTIAL ELECTR 7 , sale.If,however the building or improvement is sold within one year ofcampletion the •$Q.FL u{tBp ASQ.FI'. nenbuilder will have'be hurden ofproving that he did not build or impmve for Pat, ' / /)�� pct of sale.). V ❑I,as owner of the property,am exclusively contracting with Element amanemm to O� cantata the project(Sec.70,14,Business and Professions Cade:)She Crntmcan's Li- came Law does not apply to an owner of properly who builds or inmmves dollar,andQ1'Y, PLUMBING PERMIT FEE r4:, who contracts for such projects with a contti cians)licensed pursuant 10 de Contmemrs Lame ❑1. e t and ac. B&P C for this tenon PERMIT ISSUANCE ..a Wo ifData ALTER-DRAIN&VENT-WATER(EA) VALUATION WORK RSCOFAF ATIONAhARATION BACK FLOW PROTECT.DEVICE I he by aPmn under penalty of perjury one of the following dammatians: ❑Ihave and will maintaina CenilicateofConxmtoself-insumfor Workers ComKn- DRAINS-FLOOR,ROOF.AREA,COND. t malum,us Provided for by Section 3700 of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION walk for which this perm,is named, FIXTURES-PER TRAP ❑I have and will maintain Workers Compensation Insutan s,m required by Section 37W of the LaborGde,for the performance ofthe work for which this Permit is issued. GAS-EA.SYSTEM.I INC.4 OUTLET My Worker's Compensation Insurance currier and Policy number arc: OCC GROUP APN Comer Policy No.: GAS-EA.SYSTEM-OVER 4(EA) CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREASEJINDUSTRL WASTE INTERCEPTOR (Tris section need nal he completed it he permit is for one hundred dollars($1(10) BUILDING DIVISION FEES m less.) GREASE TRAP I certify that in the Performrce afthe walk for which this permit is iss rad.I shall W HECK FEE no,employ any person in any manrers....a becomevuhjm to the Workers'Cnmpen- SEWER-SANITARY-STORM EA.200 PT. 0 z Print Lows of Cudomia.Data Y FEE O Applicant =NEW�RMIDE�IALPLMB: ENT/ELECTR NOTICE TO APPLICANT.1[a0eI making this Cenificaa of Exemption.you shouldG FEE aI^ become subject the Weaker Com provisions ATING (y Compensation ro s of de Lahr Cade,you mustEE W Q forthwith comply with such provisions.,,his permit shall be learned reveled. WATER CONSTRUCTION LENDING AGENCY LMB. SQ.PT.U (0•SI hereby affirm Wt there is a cwuwction leading agency for the performance ofDane Rto walk(or which this permit is issued(Sec.309],Civ,C.) Lender's Name Lenders Address AL:OTAL:I cmify that I have rted tis application mJ Pum that de shove information isG FEE fff�II{Vi cmrtaL l-,me to comply with ell city and county modumnces and atom laws relating to, QTy, MECHANICAL PERMIT W building construction,and hereby Patti representatives of this city to enter upon the FEE FEEabove-mentioned Property for inspection pugwses.(We)agree to save,indemnify and keep harmless de City of Cu amt PERMIT ISSUANCEPornoag IC FEEliabilities,judgments.cosisandgrand ,eapenxawhich mayinany way acerae against saidCiry gLTER ORADD TO MECH.in consequence ofthe granting n(Nis permit NG FEAPPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT qIR HANDLING UNIT(TO IO,IXIO CFM)SOURCE REGULATIONS. NICAL FEEAIR HANDLING ONO(OVER IO,tgpCFM) UCTION TAX Stgnlnnre of ApplmanVConuucmr Date EXHAUST HOLD(WMUCD HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE Will the applicant or future building common store orhandle haralloua mrenal HEATING UNIT CTO 100,000 BTU) as defined by he Cupertino Municipal Cade.Chapter 9.12,and the Heald and Safety Cade,Section 255J2(a)]- HEATING UNIT(OVER IOQO(10 BTU) ❑Yes [I No VENTILATION FAN(SINGLE RfSID) PAID wll the applicant or furore building by the B use equipment or devices which Date 'Receipt g it hazardous air conmminantx os defined by the Bay Area Air Quality Mtnugcmen[ BOILER-COMP(JHPOR 100,gp BTU) Diuricft TOTAL: ❑Yes FlNo BOILER-COMP(OVER 100,000 BTU) I have read the hamNous mmecials moan men,under Chapter,6.95 of the Cali- AIR CONDITIONER Plain Health&Safely Cade,Sections 25505,25533 std 25534.1 understand that it the ISSUANCE DAT building does not currency have a tenant,that it is my responsibility to rally to wcupur NEW RESIDENTIAL MECH. SQ,tL ` of to mquirtmems which mull be trot Prim to issuance of a Certificate of Uccumocy. Owner or authnrizuJ again Date TOTAL: ' ISSUED BY: OFFICE -� 10300 Tone Avenue Ci1.�� of Cupertino,CA 95014 Cupertino Building Division (408)777-3228 (408)777-3333 (fax) March 24, 1997 Homeowner 820 S. Blaney Avenue. Cupertino, CA 95014 SUBJECT Permit#30471 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 records show the subject permit as finaled, would you please contact us so we may complete our records?If the permit is not signed off your permit can be reactivated and 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, f CITY OF CUPERTINO Christy Akatiff, Administrative Clerk Prinrea on Recyclea Paper