31090 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUR,UDyG-ELECTRICAL. PERMIT NO.
BGTLDING DIVISION APPLICATIONIPERMIT PLUM NG-MECHANICAL
BUILDING PROJECTIDENE11FICATHIN
BUILDINGADDRESS; SANITARY NO, APPLICATION SUBMITTAL DATE
O
LMIN
NAME: C PHONE: CONTRACTOR'S NAME: LIC O'.
( S 38- nIS Q� O NIC CCOONTTR�OL#
YRCHITIiCI NNGINHEH:CC O`LIC NO: � ADDRL'SS�:�1 t,9
1 CONTACT: I'HONe: NA///��� BUILDING PERMIT INFO
1 Consultant Fees Paid by Applicant(Initial) �J_�(� LDGF P B MECH
LICENSED CONIRACFOR'S DECLC
ARATION QTY ELETRIC PERMIT 1�IFEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(Commeaeing JOB DESCRIPTION
CMZ with Section of Division 3 of the Business and Pmfes.sions Code.and my license is RESIDENTIAL,
W- an PERMIT ISSUANCE
W C in full fame and cite
�U lu license Cmsx Li,,# 5� ❑SPUWI. ❑KITCHRN REMODEL
Fal Dme—g1Llo��—Contntn��. APPLIANCES-RESIDENTIAL DITION ❑PLUMBING NE-PIPIT
F L ARCHITECT'S DECLARATION ❑MUI.TLUNIT ❑STRUCTURAL
'NZ Iundersandm I shall he used as Public records PANT.IS MODIFICATION
ZO my
OZ4C UP T0200 AMPS El INTERIOR OCHIMNEY REPAIR
I-.�ZW Licensed Profesional 201-1000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER 1000 'S ElBATH REMODELIREPAIR ❑DEMOLH ION
Lyx Q 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
W 3 d F followin6 mics...,(Section]0315.Business aad PrufeNons Cade:Any city orcoumY SIGNS ,E L DOTTER
prorttil a which its ass s a permit to round,
the,plmc,improve,demolish,m repair any statement
E"�•O�
that he
slicenunce,also re ama inibut thovisio sfant fm such Permit Licenso Mr.e it statemen( SPECIAL CIRCO IMI5
NE�(y matboeread,meJpurstion7 hepnrvisioif3.fecBadir,,,amcenselawfChapter9
CO Ieommencing with Section 90110)..(Divisinn3of the 9usinns and PnsfessionsCMe)err TEMP.ME'IERO COMMERCIAL:
a C that he is exempt mercfmm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
_N•
Section 7031.5 by any applicant for aperiod subjects the applicant to a civil penalty of POWER DEVICES
m t ore man rive ha. m dollms(SSWL ❑TENANT ❑FOODSERVICE
F Z a IMPROVEMENT
S caner nl'mc prnpeny,nrmynnpinycc with wedfortheir
ec. 0,14.Bsiness SWIMMING POOL ELECTRIC
£p- Ida the work.eM the strvnurC is nntimended nns[farcd fns cele(Sec. Business El OTHER
IWil�m and Professions CMC.'IhC Camron ar's License law dos not apply m an owner of OUTLE-1'S-SWITCHES-FIXTURF_S
A.3.. Property who builds or impmvcs thereon,and who does such work himself nr through
his own employms,provided that such improvements are not intended or offered forNEW RESIDENTIAL ELECI'R SQ FT.
sale.IL hawevcy the huilding nrimpmv<mem issulJ within line.ycarof completion.the ARpyA LSQ.IT.
pmnm-builder will have the burden of proving that he did not build or improve for par- e ��
e of sowne
❑L as h owner of the Site 70,am exclusively ad cuntMing with licensed con-tox,mrim-
consumer
eLathe project apply
to an Business and Rvwhol os CMca The Cs thereon. Li- 1�
cense law dues nm apply to on owner of property who builds or impmvcs mmrcon.xnd QTY. PLUMBING PERMIT FEE
wbococu sforsuchpfojenswithac c dlicenwdpumuantmducCmamanev IJ DO.
Lt^e^sPERMIT ISSUANCE
❑I.. 7
a pounder .B this rcavon
1IN 11� n c a ACfER-DRAIN&VENT-WATER(HA) VALUATION
Date
WORKER. OMPENSATION DECLARATION BACK PLOW PRO ;ECT.DEVICE
Iban• y (firm under penalty of Perjury one of the following declaotiond:
f(have and dl meinmina Cenificam of Cnnncnuusclf-insure.far Workers Campcn- DRAINS-FLOOR.RWI'.ARCA.GOND. STORIES TYPE CONSTRUCTION
Iia^,as provided for by Section 3700 of the lahor Code,for the perfon^ance of the
work for which this permit is issued. FIXTUSES+PER TRAP
1 have and will maintain Workers Compensation Insurance,as required by Section
3700ofthe Labor Code,for the performuncemthe work far which this Paonal is issued. GAS-EiA.SYSTIN El OCC.GROUP APSE
My Wurkels Compensation Insurance carrier ad nPolicy numb,,arc kq
Carrier: Policy Na: GAS-EA.SYST
CERTIFICATE OF EXEMPTION FROM WORKERS' GNEASEIINDUSTR i CEPI'OH
COMPENSATION INSURANCE BUIL ) ON FEES
(Thissmtion need nolle cumPluedif the pemdt is torose.hunmuldnllurs(EIIXq GREAS'ETRAP
or less.) PLANCIIECK FE r
I certify that in the Perfommnce ofthe work forwbich this permit is ismo,l shall SEWER-SANITARY-STORM EA.2011 FT.
not Corday may Person in any manner so as nt became subject to the Workers'Compcm ENERGY FEE
C)Z cation Laws of Calimorda.Dae WAIT ER HEAT FR WIVENTIELECTR GRADING FE.
Z Applicant
N NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM?REATING
become subject to the.Worker's Comper,aion provision,of the.Labor Cade,you moa SOILS FEE
fl] forthwith comply whh such provisions or this Permit shall he deemed rcvaked WATER SERVICE
Q
� z CONST RUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID pate Re iPtp
U Ol hereby Saturn that there is a conswnion lending agency for the pctfommnce of
L✓ the work for which this permit is issued(Sm.NN7,Civ.C.)
U Lender's Name TOTAL:
Lender's Addre, �
r (Ll BUILDING PE'
1 agree that I have read Thirty arm County ordinances dram the me above information is
E" raj buildn.lagtmommand wire allcityriz nmmyes, f and smmlaws r clam
a QTY. MECHANICAL,PERMIT FEE
U ,� building construction,and hereby authorize repreanmtivcs of this city to corer uM'nth^ S[ISMIC Fr 2 �
above-mentioned pmpeny for inspection putpous. PERMIT ISSUANCE Z
(We BrcemsaC. indemnify and keep harnle,ode City of Cupertino against ELECTRIC E
linhihties' of enty,ttrsts and expenses which nmy in any way accrvc against said Ciry pLTEN ON ADU TO MECH.
11
ancon u ac of the gmntingofthispermit. PLUMBING FEE
API .\ T tNUERS'fANI 'AND WILL CO PLY WITH ALL NOJ-P INT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FEE
SOI I . EG ILATIONg. J '` (�
AIR HANDLING UNIT(OVER IQIXp CFMU CONSTRUCfI%TAX
SiEnZzurc fAP IiCmz Co^vaemr Dam EXHAUST HOOD OVIDUCT) HO USING MITIGATION LL"
HA"RDOUS TRIALS DI. 'LOSURE
Will the.opplicunt or future huilding upatt.aorem handle hazardous material HEATING UNIT(FO 100,000 BTU)
a,defined by me Cupenino Municipal Cade.Chapter 9.12,and the Health and Safety
Code,Section 25532007 HEATING UNIT(OVER 100.000 BTU) /Es
❑Yesn No O
VENTILATION FAN(SINGLE RESID) Receipt
Will the aPPlicam or lbeare building occupant use equipment or devices which r
hazardous air contaminants as definWb the Ba Area Air Qual ity Management BOILER-COMP DHP OR 1(10.(10(1 BTUl
1 Y Y Bemen TOTAL:
rap BOILER-COMP(OVER 100.0B)BTU)
❑Yes ❑Nu
I have rc:ul the hazardous materials rtquirenmms under Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCE DATE
htmia flcahh&Safny Calc.Scniuns 25505.23531 aM 25511.1 undersmnJ that if the NEW RIElIUEN'IAL MECH. SQ.FT.
building does not Currently haven tenant,that it is my responsibility to notify,the occupant
of me as,immems whicli am,i he met prim m issuance of a Certificate of Occupancy.
Owner or moth...zaJagent Doc ISSUED BY: i
—OFFICE
0citv
10300 Torre Avenue
Cupertino, CA 95014
of'
Wl Pel'tll10 Building Division
(408) 777-3333 (fax)
February 23, 1999
Homeowner
10490 Madera Drive
Cupertino, CA 95014
SUBJECT: Permit# 31090
Dear Owner:
We have been going through our files in the Building Department, and contacting those
people with permits remaining "open".
According to our inspection records, this permit has not been signed off by the 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
Printed on RCGyLIed Paper