29616 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. 29616 9^1 C
BUILOIIJCDIVISION APPLICATION/PRRMIT PLUMBING-MECHANICAL. L YV1 0
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: - - - SANITARY NO. APPLICATION SUBMITTAL DATI
Cc Liv
O 'S NAME: PONE: CONTRACTOIA�l 50 R' N{M iJ^ LIC NO:
h/ Kr N/C CONTROLM
CARCHITE /ENGINEER: LIC NO: ADDRESS: /
?-t�IA2 �7c+T ❑
CO r.. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECPRICPERMIT FEE
1 hereby affirm not 1 am btemeni ander provnbma of drapermm
9 cenendng JOB DESCRIPTION
no with Stttion]000)of DivisionJofNe Businessend Rofessions Code.and mylicenso is RESIDENTIAL:
ad in full forcR and PERMIT ISSUANCE
�W� .� G ❑SFDWL ❑KITCHEN REMODEL
�U License Clan Lic.p APPLIANCES-RESIDENTIAL []ADDITION C1 PLUMBING RE-PIPE
7�- Dale L nvuctnr
,DAS ITE SDECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
ZOv!��Z a m Iy9d � an II umdropublicfecords MODIFICATION
OZ
=10 C' UPTO200AMPS C1 INTERIOR [I CHIMNEY REPAIR
1-q4 I.Y4 Lmemed Plixtestional 201-1tOB AMPg IMPROVEMENT
W 6 OWNER-BUILDER DECLARATION OVER 1000AMPS I ❑BATH REMODEVREPAIR'❑DEMO[MON
0 1 hereby affirm on 1 um exempt from the Contractor's r'a License Law for Ne
a4 U following reason.(Selma 7031.3.Business and Professions Code:Any city r county SIGNS ELECTRICAL El OTHER
4 O wNch requims a permit m conswcl,cher,improve,demolish,or repdr any swcmre- 4Z I
s prior to iT issuance,also requires the applicant for such permit to file a signed stmemenl SPECIAL CIRCUOUMISC. t
} Nat he is licensed pursuant to the provisions of the Commuters License Law(Chapter 9
<f (commencingwith Section of Division 3 ofthe Business and Professions Cade COMMERCIAL:
) )or TEMP.METER OR POLE INST.
4 p O that he is exempt therefrom and the basis for the alleged exemption.Any viwlmion of ❑NEW BLDG/ADDITION ❑DEMOLITION
Q� Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of POWER DEVICES
u7 rn (-]TENANT ❑FOOD SERVICE
(- t more than five bvrmdreJ dollars y employees
IMPROVEMENT
1,atbwner of the prop:ny,or myemntended oroferedA wages trim(Sec. 044,8 sins, SWIMMING POOL ELECTRIC
will dotbe work.and theswmure is not inendeJorofferedfnrule(Sec.]04,1,Business ❑OTHER
4 mod Professions Came:The Connectors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
properly who builds or improves thereon,and who does such work himself or through -
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTS SQ IT.
We.If.however.Ne building or improvement is sold within one yessidevmpletion,Me SQ.F,FLOOR ASRBAj VSQ.FT
owner-builJer will have Ne burden of proving that he did not build or improve for put-
- pose of sale.).
❑ L as owner ofthe property.am exclusively connecting with licensed contractors to TOT
...mutt the project(Sec.7(fol.Business and Professions Coxa)The Contractor's Li- APR 211996
cense Law does not apply to an owner of proprty who builds or improves domon,end QTY. PLUMBING PERMIT FEE
who contracts for such prows;with a coefficient)licensed pursuant to the Conlmcmes
License Law. PERMIT ISSUANCE Ur GUI cit I11VU
I am exempt under Sm. ,B&P C for this lesson
�
QWnmCI Doe
ALTER-DRAIN&VENT-WATER(EA) VALUATION, ,
WORKER'S COMPENSATION DECLARATION BACK FLOWPROTECT.DEVICE
1 hereby ill man under penalty uxperjury one of the following d orkees o
❑er,as and will for byneCion37M if Centime seim.far for Workers Com pen- DRAINS-FLOOR,ROOF,AREA.COND. .STORIES TYPE CONSTRUCTION
codon,as provided for ni Section 3]00 of the Labor Cala far Ne performance of Ne
work far which This permit is issued. FIXTURCS-PER TRAP ,
L;.,Kave and will maintain Workers Compensation Insurance,as required by Section
3700ofthe LaborCede,for the nommnc<-fill work for which This permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Work s oto mintion1 uyketamerand Policy um rl��
Curve' u�ip�.�et y(�Policy No.:�'d�:t�2W!&n GAS-EA.SYSTEM OVER 4 HEA)
CERTIFICATE F EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION D3ES
(Thio aecnonnad not he compleneJ ifthe permit is imams hundred dation(SI W) GREASE TNAP
' or less.) PLANCHECK FEE
Icmify Nat inlM pe nrmntt of Ne rk forwhich has pumit is issued,lfiail SEWER-SANITARY-STORM EA.200 FT.
not employ any person ins ersoa o . subjectto the WORers'Compen- ENERGY FEE
oZ lotion Lawaof Califf a WATER HEATER WNENTM.ECTR
0 Applicant GRADING FEE
7, NOTICE TO APPL AN :If,after making this Certificate of Exemption,you should WATER SYSTEM?REATINO
abecome subject to the Workers Compensation provisions of the Labor Code,you must SOILS FEE
7
u„a foMwith comply with such Provisions or This puri,"I M deemed revoked. WATER SERVICE
d
' z
CONSTRUCTION LENDING AGENCY NEW RESIDP.NTIALPLMB. SQ.FL PAID, Date Rccciptp
V n work
which
thi lhuuherc lsa issued(Sec.
agency for the performance of ,
1Fly Ne work far which this permit is issued(Sec.3097,Cis,CJ
Lender's Name TOTAL:
V Lanisr's Address TOTAL:
0. - BUILDING FEE
I ttnify Nat 1 have tend this application and cute the the above information is
N cortect.1 agree to comply with all ciry and county omirmnca unJ smite laws rdming m QTY, MECHANICAL PERMIT FEE
U . building construction,and hereby suthmrim representatives ofthis city to enerupt Ne SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE �sy�
(We)agree to save.indemnify and kap harmless the City of Cupertino against IJV ELECTRIC FEE
Iiabilities,judgmems,costs andexpenses which may in any way accrue against said City ALTERORADDTOMECH.
in coruequence of the granting of This permit. PLUMBING FEE
APPLICANT UNDERSTANDS ANT?WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.(M CFM) MECHANICALFEE Da
SOURCE REGULATIONS.-
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Signaem of Applicant/Conuactor Data EXHAUST HOOD(WNUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant of future building occupant some or handle hamrdcus material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety -
Code,Section 25532(a)? HEATING ON IT(OVER 100,00 BTU)
[3 Yes []No VENTILATION RAN(SINGLE RESID) PAID
Date Receipt N
Will the applicant of future building occupant use equipment or devices which
mit haxuNous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3 HP OR 100,000 BTU) TOTAL: O OL
DisuicTt
[2 Yes No BOILER-COMP(OVER 100,1X0 BTU)
❑ '
I"we read mN
Ne haous materials requmerwas under CTapen6.95 ofdte Cali- AIR CONDITIONER Ja ISSUANCE DATE
fieria Health&Safely Cole,Sections 25505,25533 and 2553,1.1 traders unit That if the NEW RESIDENTIAL MECH. SQ.Rf.
building does not currently have it Twin.Not it is my Responsibility an notify the overprint
of the requiremena which most M met primo iesoanee of a Cemilleme of Occupancy.
Owner or outhonimd agent :.Date 7 TOTAL ISSUED BY:
OFFICE
• 1
10300 Torre Avenue
Cupertino, CA 95014
�4®
( ,eilt vof
Cupertlll0 Building Division
(408)777-3228
(408)777-3333 (fax)
January 15, 1996
Homeowner
11470 Charsan Lane
Cupertino, California 95014
SUBJECT Permit: #29616
Dear Homeowner:
We have been cleaning out our files in the Building Department, and contacting those
people with permits which have remained"open".
• According to our inspection records, the subject permit has never 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,
CITY OF CUPERTINO
Christy Akatiff, Administrative' erk