S 3185 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PI! rtND
RUILDING DIVISION APPLICATION/PERMIT PLUMBING-MBCHANIC'AI. 3185
BUILDING 1'KOJF.CI'IIItNfIFICAT111N
I II I I U CSS 1 SANI'1'ARV NO. #'PLIC l ION SOIf MITIAL DATE
'IRACU /TATE LIC
\V NEC CONTROL#
LI1 !CI'aNGINI?EN; IJCNO: I �� ❑
COMPACT: PHONE BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) UI ELECT' MUMS MECEI
❑ ❑
LICINSI!II CONBAcrok S DECIARATION QTY ELECTRIC PERMIT FF.E
❑a, I heahy Tonne mm I ren licensed alder Lobvision,of Chan,,v(emotrertcing JOB DESCRIPTION
wra Svelim]ap) Di " the Busircs.ab x RESIDENTIAL
W O p PERMIT ISSUANCE
aF�.U1- Inkeor ere I,ic.p [I SPLINT, ❑NITCHIN REMODEL
yQ� Date Caorixter APPLIANCES-RESIDENTIAL ❑ADDITION C1 PLUMBING RE-PIPE
F> -CIS DECLA AT PANF,IS ❑MULTI-UNIT [I STRUCTURAL
'LO I date Ionsslwll spubbcr ordn
MODIFICATION
OZ� UP'ITl2tp AMIK ❑EWER10R [I CHIMNEY RFYAIR
FNFad Pm@y rd 201-1000AMPS IhSPROVILWNT C]SWIMMINGPTXIIS
OWNRR-HUILDEULow
DECLARATION OVER (MAMPS ❑UA'I'II REMOUEUFt1iPAIR ❑DEMOLI'rIDN
e6''a as 1 hereby alma thio I am exempt ma the Coubbectors License w far the
KOaV follwing wren.ISambiri]OJ iA Busircu vW Professions Cede:Any,city or eoumy SIGNS EIF.CrRICAL ❑FLIER
ul3 4. which rtyuies a penal,m ennvmn..oblic in lot such
Peron t it tr Trym,any.uunure \
that he its i enercq rmand[ldrn Ec applicant for.wan pcmrit In ll ase,Law Clediteeill sPEG1nI.CIRCUI'rIMISC.
�} than he is littnacd puntunt totM provisionsn .f eBusies aLdcrnec l�w(Clwgcr'1
a�a� Immmcrcinguld heroin]000)nf lFvi4on Jof the Nurircssand Pmfn.:rrc Ctd:]m TEMP.METER OR POLI:INST.
� 'm r4ehot Rdi �]nJ Ltb tlrmfrvtn andfinePcrmfr the alleged esumptlnn.Any vlolvion of NEW HLIAVAUDI'I'ION E]DEMOLITION
p it mhjccts the Y n
e hundrpl'tcun aPplk-am macivil pcnJl f POWER D "Lti ❑TENANT ❑FOODSERVICE
rtZ> than five hundred rkJlen 153001. r IMPROVEMENT
6 D I.Is,mcneruf the prnpeny,u my employees with wages as their sole cvmpenvtimn SWIMMING 'RI
will&thewor-I l heelmclum is ren inimddoroffened for.sde(Sea.7044.Hnrinar \� [DOTTIER
tail oral Prouremore.Code:The Contractor's license law deers not apply to an oxner of OUTLETS-SWITC NES
proper he builds or improves tlrrnn,arid who docs ouch wmA himself m Wrwgh
Lir own cmploytt'*•pmvirkrl than such impo.Yancnu ore not inemlcd or ofmond I'or NEW RISIDP '!'Rl # 'Q
sole.If.however.the buidingerr indemor ent is sold u ithin are yearofewtpknen.thIk SQ.Fr.FLOOR AREA 5 QE1'.
n-hadder will bevy be horecr of pmnng tan h did ret build err imlmse for Pm
Pm nfudc.).
❑ L ns of the pmPed,am aclusively c nnecting with IicemN aniracton In '1(YfAL:
immorun the project(Sec.7044.Booms oM Pmfexsimts Cods,)The Comeanor's Li-
,I.
i- / -
mclasedouosr apply In annwncnf Pru Is he holds or itnprovc.r tlwrmn.and QTY. ,UM GP RMIT
whoc Low.fnr,vucM1M leulr with aumtnctndn)limped purswnt mtM1c Contranor'a
E]I sum Low. PERM U
❑lam eaemM under See ,B&PCfur this tcnwn
net ALAHER-I . &VEN'r-WAITR(EA) VALUATION
Date
WIJRKIiR'S COMIYNSAf[ON DF,CIARATION BACK RAN'PR1TfE If}vlCli 1
1 M1emby ap neo umwrpemllY^fp jurymeofthefolbwinpW Iner'%Co
Li Ihaac uralwill dl for BlnuCeni37M of the Latuo self-in forefia WnrAma Comp am URAL Ii FLO(1R, �icSf' .0 STORIES TYPECONSIRUCf10N
subs,as hick his
!re by Samoa,]. M the labor Crok,for the perfonrvuwc of the GJ
work EFor ave andM1 this pmntit is caved. PIaT S IS'
I have and will ode.fee a ptif Ct e.fiution Inmmnce,as nyuiml by Section
MyoflhelCbm Code.fee thsurrfnrrrwneaf Eewmk R u ubirM1m: pmmit u'.<.-t. GAS .SY, -:IN .J (ICC.CROUP AXIS
My ierrtrrs CamMmatien Insurvrue comer and y No.:number art:
Carrier: Policy No.: GAS IA.SYSIIJN�OVHR J(I?nl
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GR S W' STEINTIEXCEMUR
BUILDING DIVISION ALES
('ITis rutin i nem not Mxnmpletcd iftbc Perron is Leone hutulraldolluts($100) GREASETRAP -� -- --
ur Ips.] IYA
INCIIECK tyle
lanifylhuinrhenpnf x for t 's issuN.I shJl
nm mnl'loyan c na,f�s1 s b t r/Vh t t Wo "'ConiSEWIiN-SANI'T'ARY-STORM IA.2Q]Ff.
Z
.anon ENERGY ME
l s nr Card"`
min A a WATER HEAT ER WNFNUIELECI'R
z O Applievnt GRADING FEE
Z) NOTICE? JC ,a mal 4a�rTm+Tyw should WATER SYSTEMETREAGNG
1-' ; bam
vc suhjm m ore Wong...Cun.p#n tiro,pmvir...uq of the later Claw.you mast SOILS Illi
frmhwilhnmply with such povia:us or Otis pemtit shmli he dccnN evoked. WATER SERVICE
z
VClUCLPNDI AGENCY
nNEW RINIJINfIAh PhMHSQFfPAID
Ol thereby,Blinmeduimm rnatomarvetinn kmlingaloney for thperfrmveer of
NecepM
I
the wM fix which this permit eI iswai(Scc..f 7,Civ.C.) TOTAL
Q VIcndera Name '
UIcwlce,Ad[ebv, 1(JfAL'
I}' 1 1 century Brat I have read thin application aM same tlw the Jove inf.u.is BUILDING
UJ cancan 1 ages,to armply with JI city old manly odimnas real awns,laws mlarin,h' QTY.
F) Z MECI IANICAL PERMIT FEF,
building aomar tion.cost hereby aulhnue repm,crddives of this city reenter upon llw SEISMIC FEE
above-memimtcd proper for inspection purpv-v PERhiR IhSUANCE
(Ws,)agicc to save,indemnify and lccp Iufmlcn the City of Ctifee no against EB to-b-D C
babloics,judgnentn,cous and as Ioetws which tnay in nmy wayarerucaguinst sold City AL117R OR At IUTDMHCI1.
int sequence of de",in,of Eris permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITGO)IBM)CFM) MECIIANICALFP
SOURCE!REGULATIONS.
AIR HANDLING UNIT LOVER I0.00I CITE) C'ONSTRUCT'ION TAX
Sigium¢of ApplicanUConmearr Dee EXHAUSTHT()D(WIDUC) I LOUSING MITIGATION ITB
IIA%ARIXWS MATERIALS DISCLOSURE
Will the applicant or for=building occupant store or handle M1ssankxis mucrial HEATING UNIT TO 100,0Ip BTU)
ver defimM by the Cuper iso Municipal Cede.CINEe,9.12,and Be,Healtb arta SJny HEAI'IN'C UNIT(OVER 100,000 H'IV)
Cd:,Scetlon 215]2(a)]
oVes ❑Nn VENTILATION FAN(SI NGLE RESID) PAID -
Will theevif ican,or forum hchding rceupanl use evin,ramt or&,in-which Date RessoPi I
,`iht'mdwv air eonmmincUm
nduOncd he pl
by IL- Aron Au,Quality Monegement HOILI!R-COME'(3HP OR II10,M)BTU)
fll'
0Ycs 0N BOILER-COM P(OVER I Oli BTU)
1 have read the M1aaudsau marcndn es under Chapter 695 Ns,M Cali- nIR CONDITIONERrt�irt ISSUANCE DATE
Emig Health ro SJny Crile,e mneme 25305.]SSiI and 2551f.1 otdnvenl tow if the NF.W RF_SIDENHAL MI;CH. Sp.FL ^
huHalingdxs osrcuwhich have thIc 1p ricer it ismyradrace"fimunify, xcvym F--J
rd Ee mluircmm�.s which muvthrrrn prior to iorwvtce o(u Cenificac of lksvryrrry.
Owrcnr amhmireA nonan Dim LILY1TA1 ISSUE)BY:
OFFICE
rA, 10300 Torre Avenue
AeCITY OF Cupertino,CA 95014
CUPERTINO Building Division
(408) 777-3333 (fax)
October 28, 1999
Homeowner
75'4 Fallenleaf Lane
Cupertino, CA 95014
SUBJECT: Permit# S3185
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 signed off by the
I Building Department. 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 remove the records from our computer.
Thank you for your assistance.
Sincerely,
CITY OF CUPERTINO
Christy Akatiff, Administrative Clerk
1
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