30049 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
I—I L. VIP- l.L-Y61( I INVr.r.cw n...n.. ••••,••• • ••••. 30049
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION
NAME:
❑ Consultant Fees Paid by Applicant (Initial)
mmZ
I hereby aflum that 1 am licensed under provisions of Chapter 9 (commencing ".
with Swrion2001))of Division J of Ne Business and Professions Code, and my license is 1
in full force and effeel. 4
GU U License Class Lim. a
ZZW nate Cnmmco"
ARCHITECTS DECLARATION
O�` 1 understand my plans shall he used as public records
Z
F yLt.W Licensed Pr..fimowel
al OWNER -BUILDER OWNER -BUILDER DECLARATION
C C
O d Q 1 hereby affirm that 1 um exempt from the Commctors License law for the
5Sx U following reason. (SNainn 7031.5. Business and Professions Code: Any city or musty
W 3 w y ruan
which requires a permit to construct. alter, improve, demolish, or repair y stmcwrt
E]v'O4] prior to its issuance, also requires the applicant for such permit u filea signed sm6lmew
ythat he is licensed pursuant o the previsions of the Contractor's License Law (Chapter 9
(commencing with Section JNM)) of Division 3 of the Basins and Profcesicw Code)or
a X o c that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 2031.5 by any applicant fore permit subjects the applicant to a n vi l penalty of
H 2 i not mom than rive hundred dollars ($500).
^£=Q ❑I, as ownerofue protony,mtry employees with wagon us theirs ole emopensalum,
will do the work, and the Wucture is not intended moffcred for sale(See7844, Business
6 3 and Professions Code: The Contractor's License Law docs not apply to an owner of
Property who builds or improves thereon, and who does such work himself or through
hi. own employees, provided that such improvements are not intended or offered for
sale. IL however, the building or improvement is wld within one year of completion, the
owner-bu will have the burden of proving that he did not build or improve for pur-
pose m salaj.
1, as owner of the property, am exclusively contracting with licensed contractors to
anent the poject (Sec: 7141• Business and Professions Code:) The Contractor's Li
se Law does not apply to an owner of property who builds or improves thereon, and QTY
who contracts for such projects with a mntrnemr(s) licensed pursuant to the Contractors
License law.
❑rum exempla erSec. ,B&P C far that Reason
net Dam
1 herchy affirm under penalty of perjury one of the fallowing declarations:
] I have and will maintain a Certificate of Corm to self-insureforWorkersCompen-
sation./ workf r hick this
tin by is
ran 3IIe1 of the Labor Coda for tits perforomoce of tits
work for which this pcmin a tion 3.
❑ 1 have and will maintain Workers Compensation Insurance, as required by Section
3200 of are labor Code, for the performance of the work for which Ibis permit is issued.
My Worker's Contpenwlio thrummed carrier and Policy number are:
Carrier Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMP17NSATION INSURANCE
(This section need nm be completed If the permit is for nae hundred dollars ($1007
or leis.)
I certify that in the Performance of the work for which this pemtit is issued, l shal I
nor employ tiny Person in any manner sit as to become subject to the Workers' Compen-
0 z scion Luwx of California. Dare
Z Applicant
h NOTICE TO APPLICANT: If, after making this Certificate of Exemplitn, y,,a should
ai become subject ur the Worker's C ii,tradim provisions .1 the Labor Code, you most
{kI forthwith comply with such previsions or this pert shall be deemed rxvused.
a�
U z - CONSTRUCTION LENDINGAGENCY
U I for which rad
thatthemisoed See. 30 len ding agency for the penfurmance of
ny F thework for which Ibis permit ss issued lSec. 309'1, Civ. CJ
Q U lenders Name
I<nJcrs AJdrc,¢
(r-' G 1 certify ma I have read this application and state that the static information is
Z) corm,', 1 agree as comply with all city and county mJinunce, sad slate laws relating In QTY
Z building consiond w. and hereby aathorire representatives of Nis city m enter upon the
above-mentioned property for insistent I purposes.
(We) agree to save, indemnify and kttp harmless rhe City of Cupertino against
liabiliries,judgmenrs, costs and expenses which may in any way averse against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REG ILATIONS.
Stena 'ol ppbcundCnn ee 1444
Data
HAZARDOUS MAI ERIALS DISCLOSURE
Will the applicant or future building occupant store orhandle h reardous material
as defined by the Cu,cnint Municipal Code. Chapter 9.12, and the Health and Safely
Code, Section 25532(a)9
❑Yes ❑No
Will he applicant or fume, building occupant use equipment or device% which
mit havrdous air comtendnants as derived by the Bay Area Air Quality Management
Awriell
V0 ❑Yes No
I have toad the hazardous matcrialk requirements ander Chapter 6.95 of the Cali-
fomia Health & Safety Code. Sections 25505. 25533 and 25534. 1 utldswund that if the
Wilding does not cunrxndy have o motor, that it is my responsibility to notify the occupant
of the WFiremen¢ which must be met prior to issuance of a Certificate of Ceinpanry.
Owner or autharimd agent Datc'
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES — RESIDENTIAL
PANELS
UPTO 200 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUUUMISC.
TEMP. METER OR PULP INST.
POWER DEVICES -
SWIMMING POOL ELECTRIC
OU'TLE'TS - SWITCHES — FIXTURES
SQ IT
PERMIT ISNIANZW
ALTP,R—DRAIN VEM TER (F,A)
BACK FLOW PROTE., . )EV
DRAINS— FLOOR. ROOF. AREA, COND
FIXTURES — PER TRAP
GAS — CA.SYSTEM-1 INC, 40 BTS
CAS—EA,SYSI'EM-OVER iAs
O:
G-
NIC CON'1'kOLa
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
FEE JOB DESCRIPTION
' RESIDENTIAL
❑SFDWL ❑ KITCHEN REMODEL.
❑ADDITION ❑PLUMBING RE -PIPE
❑ MULTI -UNIT ❑STRUCTURAL
MODIFICATION
❑ INTERIOR ❑ CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEUREPAIR ❑ DEMOLITION
❑ OTHER
of
OMM R IA
❑NEW BLDG/ADDITION C1 DEMOLITION
11 TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑OTHE•R
SQ. FL FLOOR AREA $/SQ. FT.
1q3$
FEE
VALUATION
GREASUINDUSTRI.W .TEINTEKCEPTOR
BUILDING DIVISION FEES
k,0CKPEEARY..S'Ila E )
CKIRGY FEE
MTRAP,,
R WNEM'IELECTR
GRADING FEE
lTREATING
SOIL$ FEE
EIAL
PAID
Date Receipt a
PLMR. SQ. Ef.
TOTAL:
TOTAL:
BUILDING PF,E ^r
C�
MECHANICAL PERMIT PEE
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC FEE SO
.ate
ALTER OR ADDTO MECH. O
PLUMBING FEE
AIR HANDLING UNIT (TO 10,00ll CPM)
MECHANICAL FEE
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD (W/DUC)
CONSTRUCTION TAX
HOUSING MITIGATION FEE
HEATING UNIT (TO 100,0110 BTU)
HEATING UNIT (OVER I W.000 BTU)
PAID
Date Receipt g
VENTILATION FAN (SINGLE RFSID)
BOILER —COMP QHP OR 100,M) BTU)
TOTAL:
BOILER —COME (OVER 100,000 BTU)
AIR CONDITIONER
ISSUANCE DATE
'
NEW RESIDENTIAL. MGCH, SQ. n'.
OFFICE
ISSUED BY:
January 15, 1996
Homeowner
10530 E. Estates Drive
Cupertino, California 95014
SUBJECT Permit: #30049
Dear Homeowner:
10300 Torre Avenue
Cupertino, CA 95014
Building Division
(408) 777-3333 (fax)
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 CI'erk
0