30666 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT N030666
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BUILDING DIVISION APPLICATION/IaERMIT PLUMBING-MECHANICAL JK F6 6 F6
BUILDING PROJECT IDENTIFICATION
BUIL0DINGADDRESS: IVB LLS 1,A)1,A) SANITARY NO, APPLICATION SUBMITTAL DATE
1 �/ppM3p/��C/a�
G M1vrJ�.g'1 A- pe DSubRr CONTRACTORS NAME: LIC NO: NIC CONTROLly
HITECT/F.NGINLER: LIC NO: ADDRESS: ❑
CONTACT: - PHONE:
BUILDING PERMIT INFO
Wit ;),rA (
/q, ^ El Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
Wit
J � Z?' ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEP.
G m Z I heathy oRrm unit 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
with Sumon 7000)of Division 3 of the Businesitaf ProNscions Code.andm license is
p0 y PERMITISSUANCE RESIDENTIAL
trial force and effect.
PUU ❑SFDWL KITCHEN REMODCI.
k.V U License Class Lia.N
yQS Dam Conuucmr APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
pan ARCHITECTS DECLARATIONPANELS - ❑MULTI-UNIT ❑STRUCTURAL.
Z '117, 1 understand my plans shall he used as public recordsMO IFlCATION
02:10 UPT0200AMPS E)INTERIOR NEY REPAIR
rLicensed Professional 201-1000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER 1001)AMPS BATH REMODEVREPAIR ❑DEMOLITION
I hereby affirm that 1 am ewmpr from the Comosion s License Law for the
5340 following mason.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL OTHER
F=0which requires a permit to conant alter,improve,demolish,or repair any somctum
odor I.it.issuce,also requires rhe applirmt fumeh permit to fileasigned statement SPECIAL CIRCUIT/MISC.
G� Nat he is liancensed pursuant to the provisions of the Contracmrh License Law(Chapter 9
Dp (commencing with Section 7000)of Division 3 of the Business and Profusions Cods)or TEMP.METER OR POLE INST COMMERCIAL:
6 0 tY that he is emmpt therefrom and the basis for the alleged esemption.Any violmom of ❑NEW BLDGIADDITION El DEMOLITION
ts• Section 7031.5 by any applicant for a Permit subjects the applicant a civil penalty of POWERDEVICES.
�� ❑TENANT ❑FOOD SERVICE.
1p,,,ZZ of more than five hundred dollns($5007. IMPROVEMENT
G ❑1,as ownerofthe property.or my cmpinyms withwages as their xnlecompensntinn. SWIMMING POOL ELECTRIC wJl do the work,and the stmcmm is tmr intended or offered far sale(See.70,13,Business ❑OTHER
and forms inna Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself nr through
his own employees,provided tont such impmvementa ore ant intended or affered far NEW RESIDENTIAL ELECTR SQ PT.
sale.If,however,the building or improvement is sold within one year of completion,the - 0, SO.PFA01 ADA g/SQ.Fr.
owner-builder will have the burden of proving that be did not build or improve for pun
pace of sale.). DECL as owner of the property,am exclusively Controlling with licensed contractom m TOTAL G 1
construct the project(Sec.7014,Business and ProCede:)
Professions The Comruemes Li- 31996
cerise law does nm apply to an owner of pai who builds or improves thereon.and QTY, PLUMBING PERMIT F E v v
oho amuacm for such projects with a mntmclarsd licensed putsmnt to the Coma ants
License law. PERMIT ISSUANCE fY ur wrenI iiqu
Iamexemtaadcr Sec. ,B&PCfo hist n
AL7LR-DRAIN&VENT-WATER(EA) VAWA71ON
Owner )m- 00
I�
ORKER. C PENSATION DELLA- N BACK FLOW PROTECT.DEVICE l o i
(hereby affiant under penalty of perjury one of the followin eclmavou:
I have and will maintain a Certificate of Consent to self-insure fo Warker's Camper- DRAINS-FLOOR.ROOF,AREA.CORD. STORIES TYPE CONSTRUCTION
ration,as provided for by Section 37M of the Labor Cale,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,os required by Section
3700ofrhe Littor Cede,far the perfmarmilecif the work for which this permit is issued. GAS-EA.SYSTEM-I INC.J OUTLETS OCC.CROUP APN
My Worker's Compensation Insurance carrier and Policy number arc:
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 6 PA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASOINDUSTRL WASTE INTERCEPTOR
(This—imposed nabee campleted if the permit is Torose hundred dollen(Soto) BUILDING DIVISION FEF_S
GREASETRAP
or le".) PLANCHF.CK FEE
Loy anytheto the performaany
of the becurnamoork u this perthe Wi kensC,lshall SEWER-SANITARY-STORM EA.2M FT.
not employ"want
oemm iany manner so as m become subjecua the Workers'Compen- ENERGY FEC
,2 Applilaws of California.aDam
Z Q Applicant WATER HEATER WNENT/ELECTR GRADING FEE
VJ NOTICE.TO APPLICANT.If,after making Nis Cerificme of Foamed.., ..should WATER SYSTEMRREATING
abecome subject to the Workers Compensation provisions of the Leon Cale,you must SOILS FEE
Lkl forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION.is.eLFNDINGAGENCY NEW RESIDENTIAL PLMR. SQ.FT. PAID Date Receipt V Thor which hi that ft.iso ed(So(So.307,
C.) cy for the perfomtvnce of P
p the dark for which this permit is isxucd tgtt.3T9],Civ.CJ
!"' Lender's Name TOTAL:
Leader's A mots t TOTAL:
y I certify that l have read this upplicadm and cram that the above infartnation is BUILDING FEE
h concert.l agree to comply with all city and county ordinances and nam laws relating to QTY. MECHANICAL PERMIT FEE
LIZ building construction,wall hereby minnow representatives of this city to enterupon the SEISMIC TLE
.have-mentioned porosity for inspection puryoses.
(We)agme to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC ME
liabilities,judgments,costs and expenses which may in my way sceme against said City ALTER OR ADD TO MECH.
in consequence of the gmnfing of this .it. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0.000 CPM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CITI) CONSTRUCTION TAX
Signature of ApplicanVContrecmr Date EXHAUST HOOD(W/OUCTI HOUSING MITIGATION FEE
HAZARIX)US MATERIALS DISCLOSURE
Will theupplirmumfumre huiliingoeeup.nt mmcmintrdleharmdousmmerml HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
Castle,Swum 25532pd? HEATING UNIT(OVER 100.030 BTU)
El Yea ON. PAID
VENTILATION FAN(SINGLE RESID) Dem Reced,
Will the applicant or future building occupant use equipment or device which
mit harallous it comaminams as defined by The Bay Area Air Quality Management BOILER-COMP(3HP OR I W,1X10 BTU)
Msmm:' TOTAL:
❑Yes 7 N BOILER-COMP(OVER 100,000 BTU),
1 have read hazardous
the materials requirements under Channel AIR CONDITIONERr 6.95 of the Cali — ISSUANCE DATE
farms Health&Safety Calc,Sections Z!1505,25533 and 25536.1 understand that if the NEW RESIDENTIAL MECH. ,.SQ.FT.
building does nm currently have.mann,that it is my almoreibility m amify the cations, -
of the requirements which must he met prior to homm of a Certificate of Occupancy.
Owner ar aathoriwd agent Data TOTAL: ISSUED BY:
OFFICE
&C,tv
10300Torre Avenue
of Cupertino,CA 95014
Cupertino Building Division
(408)777-3228
(408)777-3333 (fax)
June 18, 1997
Homeowner
1043 Colony Hills Ln
Cupertino, CA 95014
SUBJECT Permit#30666
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 had a final inspection.
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 dispose of the file and remove the records from our computer.
Thank you for your assistance.
Sincerely,
CITY OF CUPERTINO
Christy Akatiff, Administrative Clerk
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