29300 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
t,. CITY OI'CUPERTINO BUILDING-ELECTRICAL. PERMITNO, 29300^ 3 0 0
BUILDING DIVISION APPLICATION/PERMIT - PLUMBING-MECHANICAL Ls4J
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
O NCR' N ` PHONE: CONTRACTOR'S NAME: LIC NO:
1 J /,- _NIC CONTROL#
CHITECGENGINHE :, LICNO: ADDRESS: ❑
'ONTACT. PHONE:. - BUILDING PERMIT INFO
OIJ41 j L. (��d� er�_a[y/8 ❑ Consultant Feu Paid by Applicant(Initial) BLDG ELECT PLUMB ' MECH
..7 v 1 1 'Y �! .J -�T- ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY F.LECFRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
CR5104Z with Section 7")if Division Sof the Business and Professions Code.and my liana is RFSIDFNTIAI:
FWD in(ull peace and effect PERMIT ISSUANCE CSFDWI. ❑KITCHEN REMODEL
<V License Class Lie.Is
y< Dam Contractor APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
(.,50 ARCHITECTS DECLARATION PANELS [IMUI.TI-UNIT, El STRUCTURAL
OZ n-4 1 understand my plans shall be used as public pounds MODIFICATION
0Q4H:J - UPT0200AMPS El INTERIOR El CHIMNEY REPAIR
Licensed Preresamed 201-INVAMPS IMPROVEMENT
C bd T_,^I atI conexemptOWNER-BUILDER DECLARATION OVER IWAMPS ❑BATH REMODEUREPAIR [I DEMOLITION
3 O t'U I hereby affirm on 1 E exempt from the Commis C's e:Any c Law(m Ne
WU followingures a (Section]03115, t.alter, and Professions h.Me:Any city or county SIGNS ELECTRICAL OTHER
Cwhich requires issuance,permit re conswa,alter,i t for su detmli.sh,or repair any swment
�uyQ psiunoits lendpennant to theres provisionofor Cannoch t rile a
La dsmmmem SPECIALCIRCUIT/MISC. '
i+•.•1l that he Indo,with
punuam 70th,of Division 3 the Conwness nd Professions
Code)or
a0 (hotrtmes could tSereion]Orid the
basis for
the
the Business Professions Cale)or 'TEMP.ME'1'F.R OR POLE INST. COMMERCIAL:
6 q o K that he is exempt therefrom End the basis for the cts the exemption.Any violation of El NEW BLDG/ADDITION [:1 DEMOLITION
fiYC {r. ]011.36y any applicant lora permit xhjecta the applicant toncivil penalty of POWER DEVICES �p�NpNT ❑FOODSERVICE
t thanfivchundr,ddollam($500f /-
F IMPROVEMENT
Miw.cr.f,hc prapcny,ar my employtts with woges.their sole compensation, SWIMMING POOL ELECTRIC
the work,and the stmcture is not imendW proffered forsale(Sec.]M4,Business C OTHER
_ fessions Cade:The Contractors License Law does not apply m un owner ofOUTLET -SWITCHES-FIXTURES
pmpen who builds or improves thereon,and who does such work himself or through
EL-
his own ployees,provided that such impmvements are not intended or offered for NEW RESID EST IAL ELECTR SQ IT.
sale.ILho ever,the building or improvement is sold within one year oenmpletion.the SQ.Pr.FLOOR AREA ESQ.Fr.
pw,less l r will have the burden of proving that he did nit build or improve for pnr- "
meor sale.. P A o U
1,m ow r reject
the property,am exclusively contracting with licensed commcmrs to
pnswn e d traject(Sec.?an Business and Professions Code:)The Cpnn icon.and
cenxinwdo x not or suchapply roan with
aorpmpenywhosedTrrito to the C'mann.and QTY. PL1IMBING PERMIT FEF.
whocennacts or such
LClceimassw. PERMIT ISSUANCH FEB1' 19L,�
lam exam made,Sec. ,B&PCI'or thisrcnm
Owner Datc ALTER-DRAIN&VENT-
WA :A) LDH,,
+I
.WORKER'S COMPENSATION DECLARATION Jr W lr�aTLnIIJYU
BACK FLOW PROTECT.DEVICE
1 hereb aRw underpenalty of perjury one of the following declarations:
Ihaveand 'll ttmimain eCcrtificam of Conxnuo ull'.iruure for Wmkcr's Cempen- DRAINS-FLOOR.ROOF,AREA,COND. STORIES TYPECONSTRUCITON
mien,as pmvi ed for by Section 371X1 of the Lnbor Cale,rim the per0nmonce of the
work for which hispermit is issued. FIXTURES-PERTRAP
C 1 have and ill maintain Workers Compensation Insurance,as required by Section
3]00e(th,La in Code,for the itdowaweof the work for which this permit is issued. GAS-HA.SYSTEM-I INC.4 OUTLErS
OCC,GROUP APN
My Worker's C tmpensation Insurance carrier and Policy number are:
Cartier: Policy No, GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE:OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
I (This cuonncednotbecompletedifthepawitisfunme hardreddoBars(Sl0p) GRFASI?TRAP
or less.) PLANCHECK FEE
Iceni Ohminthe anymanerof slabsekfor which this permitisirs Conarem. SEWER-SANITARY-STORM EA.200 FT.
oat employ y person in any manner so as become subject m the Workers Cnmpem ENERGY FEE
��]] z nation Laws fCalifomie.Dam WATER HEATER W/VENT/f?LECTR
a; O Applicant GRADING FEE
NOTICH T APPLICAN'C IL after making this Certificate of Exemption,you should WATER SYSTEMRTEATING
f! t' become so jecuo the Worker's Compensation provisions of the Lahor Cod,you must SOILS FEE
forthwith Imply with such provisions or this pewit xha116e dcemW rcvoknl. WATERSERVICB
a 0
aO CONSTRUCTION LENDING AGENCY, NEW RESIDENTIAL PLMB. SQ,FT. PAID Date Rec,it#
I ereby uffiw Nmthere is ocunswetion lending agency froth,perfowance of P
thewor for which Nis peut is issued(Sec.30Civ.C.)
LT.t rr99•U Lender.Nam - TOTAL:
Lender' Address - TOTAL:
certify Nm 1 have read this npplice itin and state that Ne above in(owation is BUILDING FEE
(A cone',l agree to comply with all city and county ordinances and slate laws behi ing m QTY MECHANICAL PERMIT FEE
U i� buildgconstruction,and hereby motorise representatives of Nis city to enter upon the SEISMIC FEE
abov ruminated property for inspection purposes. PERM IT ISSUANCE
seso
(We)agree to save,indemnify and keep mmuless the Ciry of Cupertino again ELECTRIC FEE
is itis, udgmerm.cpsts and expenses which may in any way accrue again said Ciry ALTER ORADD TO MECH.
PLUMBING FEE
quence o(the gmmiof Nis permit'
A N N ERSSRi DS AN ILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITOO I0,rkYCFMj MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,00)CFM) - CONSTRUCTION TAX
,dam of p icaro'Ciumalm- Vale EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will thert,licant or future buildingoccupmo,areor handle hasardous mmedal HEATING UNIT(T0100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 8532oj? HEATING UNIT(OVER 100,013 BTU)
CYes t• CNe VENTILATION FAN(SINGLE RESID) PAID
Dam Receipt#
i;d me applicant or future building occupant use equipment or devices which
'mit hazallous air cnnmminants as defined by me Bay Arca Air Quality Management BOILER-COMP(lI1POR 1(10,000 BTU)
can't? TOTAL:
❑Yes E]No BOILER-COMP(OVER 100,000 BTU)
1 hove read the hazardous materials requirements under Chager 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE,
forma Health&Safety Cade.Sections 25505.8533 end 25534.1 understand mat tribe NEW RESiDHN'rIAL MECH. SQ.IT. 1.
building does not con only have a tenant that it is my responsibility to reply the oacupam
of the regalfemenH which must M met prior to issuance ora Ccrol of Occupancy.
Owner or authorized agent Date TOTAL ISSUED BY:
OFFICE
c®• 10300 Torre Avenue
Cupertino, CA 95014
Cl perthlo Building Division
(408)777-3228
(408) 777-3333 (fax)
January 15, 1996
Owner/W.Rickman
10321 S. De Anza Blvd
Cupertino, California 95014
SUBJECT Permit: #29300
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 ClerM
0