29354 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT
PLUMBING-MECHANICAL.
29354
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANI'T'ARY NO. APPLICATION SUBMITTAL DATE
tCi::-) s3 v -L, S
OWNER S NAME:( 1` PHONE `_ / C fJTRACTOR:S NAME: LIC/NO.
fir— \ :V.GJ4: ! - '.J C? `�Pf Y)' �e L, I'/t q%'✓�5]! NIC CONTHOLp
RCIII'I'ECI'IENGINEER: LIC NO: ADDRESS: +.1 `1 ❑
ONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 herehy Sffirn that I am licensed ander provisions of Chapter 9(commencing JOB DESCRIPTION
w0cC=Z 'th Saam.7lXXUofDivision 3ofthe Business and Profession,Code,and my license is RESIDENTIAL
a gk— w PERMI'I'ISSUANCC
Fes., in lull fora and efeeT. - r()� ❑SFDWL ❑KITCHEN REMODEL
SZUV License Class `' �l7 I.m.0 `'' API'LIANCIiS-RIiSIDENTIAL []ADDITION ❑PLUMBING Rfii'IPE
hQL Dine Cnntrunnr
ARCH[11r,C'PS DECLARATION ❑MULTI-UNI"r ❑STRUCfURAI.
zgnn I understand my plans shall be used as public record, PANELS C7 MODIFICATION
OZ—� UPTp 210 nMY5 (� if El CHIMNEY REPAIR
F.FW Licensed Professional 201-10N)AMPS IM11PR T
OWNER BUILDER DECLARATION
OVER["AMPS ❑BATH REMODELrREPAIR ❑DEMOLITION
C C Q 1 hereby affirm that I am exempt from the Comracmrs License Law for the
X 316 F- fallowing reason(Section 7011.5.Business and Peofeeamm Code:Any city ur county SIGNS ELECTRICAL []OTHER
y¢ which rectums a Permit to cautioned,alter,improve,demolish.or repair any nracture
prim to its issuance.also reyums the applicant for uch Permit o file m signed Statement SPECIAL CIRCUIT/M ISC.
that he is licensed maxium 1.he provision,of the Contractors License La.(Chapter 9
�y'�� (commencing with Section7N)0)of Uivi,ion 3o fine Business and Professions Core)nr TEMP.MET ER OR POLE INSTCOMMERCIAL,
a 6 c that he is exempt therefrom and the nasi.Tali the alleged exemption.Any vielation of n( ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 911315 by any applicant for a pennil wbjms the applicant n a civillmemnity of POWER DIIVIC17S
^h ❑'
t more than five hundred Jolhus(MM). (� IMPROVEMENT ❑FOOD SIiRVICI:
C
FSI.as owner l
f the propel,or my employees with wages a,their sole cnmpainiamn, SWIMMING POOL ELECTRIC �' IMPRQVEMENT
Q
$a'(... well do the walk,and the swchum is not intended or offered for sale(Sm.7044.nosiness ❑OTHER
u1 and Professions Cole:The Conviction's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improvci thanes,and who does such work himself or tMmgh
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELEC1t SQ FT.
sale.If.however,the building or improvement is sold within one year ofcompletion,the SQ.FT.FLOOR AREA S/SQ.FT.
owner-builder will have the human of proving that he did not build or improve for Pur.
pom of sale.).
0 1,as owner of the property,am exclusively contracting with licensed contractors In 4 ftsv
TOTAL: aa��
construct the project(Sec.70114.Business and Professions Code:)The Contractors Li- H 9
cense Law does not apply to an owner of property who builds or improves thereon,and QTY PI, BIN IT FEE t� 1996
who evarealsRusuch projects withm ¢m
acm � rlq Iiron+eJ ptistem hr the Conlon, r', l
I.n'enae l.aw. PERMIT ISSUANCE (,ll` Vh
1 ant exempt under Sec. .B&PC for this mann L(Jl_`fl I In•r a
Owner Dam ALTER-DRAIN&V' T- ATER VALUATION
WOR KER-S COMPENSATION DECLARATION BACK FLOW PROTECE Ey/C
1 hertby affirm anter penalty of perjury nnc of the following decimations:
Tial andwillmaiimin aCenificamnf Consent msdf-insure for Worker'sCmmpcn- DRAINS-FLUOR.ROOK AREA, STORIES TYPE CONSTRUCTION
workprovided for by Section 3700 of me Labor Code,for the performance of the
for as which this permit ix issued. FIXTURES-PER TRAP
1 have and will maintain Workers Compensation Insurance,as required by Section
3700ofthe Labor Cafe,for the NrfornOn.ofine work forwhich this rysmit is issued. GAS-EA.SYS, INC.40UTLLTS OCC.GROUP AI'N
My Worker's Compensation Insurance curia and Policy mumhor arc:
Carrier: Policy No.: GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF;EX EMPI'ION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRI.WASTE INTERCEPTOR
BUILDING DIVISION FY:IS
(Thissectinn need not be completed ilthc Permit is Formic hundred dollars(SINE GREASETRAP
or las.) PLANCHECK PEE
[certify that in the perfonnanmofthe work for which thn,mait is issued,[shall SEWER-SANITARY-STORM EA200 FT.
not employ any peon in any manner ata t become suit t.the Wmkcrs' .Compen- ENERGY FEE
Q ,Z satins laws of CA'Ta,.,: n,e L/ C/Sri WATER HEATER WNENT/ELECTR
r
Applicant /I GRADING IEE
NU' APPLICANT.If,after making this Certificate of Exemption,you+hmuld WATER SYSTEM?BEATING
F "'1 object to the Worker's Ciera tis lithe Labor CIJc,you most
SOILS LYE
became
j pens, n Provisions n
forthwith comply with such provi,io vior this pennil shell be deemed revoked. WATER SERVICE
Q
Uz CONhem is a'IONLENDINGAGENCY NEW RIiSIUIiN'I'IAL PLMB. SQ,F7. PAID Date cci to
C.7Ql hereby which ad mermen issued(Sm.30lending agency for the perlirmancu of p
the work Bn which this pennil is issued(Sec.3tH7,Civ.CJ
D" U Lenders Name TOTAL:
0 V Lente Address TOTAL:
I cert
�s R7 BUILDING FEE
that I have mad this epPlicaliun OMI Slate that the above information is
F" y correct.I agree to comply with all city Said county ordinances and nate laws relating to QTY MECHANICAL PERMIT FEE
V,Z building commuction.and hereby authorize representatives ofthis city m enter upon the SEISMIC FEE
.Nice mentioned property for inspealon pmpasca. PERMIT ISSUANCE
(We)agree to save.indemnify and kap hamdess the City of Cupertino against ELECTRIC FEE
liabilities.judgmcnts,cosuard,spe.w.,which may many way same againstand City ALTER OR ADD TO MECH. PLUMBING FEC
in mw,md.of the granting of Thi,permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL )N-POINT AIR HANDLING IINIT('TO 1800)CPM)
SOURCE REGULATIONS. � MECHANICAL VE
7 CIl AIR HANDLING UNIT(OVER 10.000 CEM) CONSTRUCTION ' %
Sig aturt of ApplicanUConaanor Dam EXHAUST HOOD(WMUC17 HOUSING MITIGAT NFEE
HAZARDOUS MATERIALS DISCLOS RE
Will the applicant r dome building occupant store or handle lanadoue material j HEATING UNIT CFO 100.000 BTU) l
as defined by the Cupertino Municipal CoJc.Chapter 9.12,and no Health s J Safety
Code.Section 25532(x)? HEATING UNIT(OVER I Bidet BTU)
❑Yes C]No PAID
VENTILATION FAN(SINGLE RESID) pine R¢ciptN
Will the applicant or future building occupant use equipment or devices which
mil hmardnm air conmonara ,Ice defined by the Bay Arca A.,Quality Munagenwnt BOILER-COMP(3HP OR 100,1X)0 H'IU) BAAI.
mm l BOILER-COMP(OVER 100.000 BTU)
❑Yes ❑No
I have read the hasardoua malmala yuiremems under Chapter 6.95 of the Cali.. AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Cale,Sean,.]5505,25533 and 25534.1 anda¢and that if the NEW RESIDENTIAL MECH. SQ.FT.
building docsnm cu whicheady have he met prior
o ismyofaernificanotify thepraco
ofthe rey oesmilewldch man bemetprior to is my noon Ccnty to ropy
the ceakiN
^Y—dry/71�/
Ownef m aumorisJ agent Dom TOTAL: ISSUED BY:
OFFICE
10300 Torre Avenue
Cupertino, CA 95014
City of
Cupertino Building Division
(408)777-3228
(408)777-3333 (fax)
June 18, 1997
Homeowner
20253 North Cove Sq.
Cupertino, CA 95014
SUBJECT Permit#29354
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
Prnnfod an Recvcled Paper