28889 (2) APPLICANTTO'FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT No.
'BDIEDIRG DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 28889
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
� .
O NE: P N CO ACTOR:SN ME: L
/J I O /J1 NIC C R L
ARCHITECT/ENGINEEIL L NO: ADDRF. S. ❑
CONTAC. PITON]:: BUILDING PERMIT INFO
Cons.tent Fees Paid by Applicant(Initial) BLDG ELECT - PLUMB MECH
i ' G fsS= � ❑ ❑ ❑
TICS- SI3U CONTRACTORS DECI„AR ION QTY. ELECTRIC PI3RMIT 17EF
1 hereby affirm that I um licensed under pnwisirms of Chnpmr 9(commencing JOB DESCRIPTION
pOjOp with Section]OWI of Division A of the Business and Professions Code.and my license is PERMIT ISSUANCE. RESIDENTIAL;
F fa11 notes sae c(r
1O �'�z �G���. ❑SIV WL ❑KITCIIFN REMODEL
WUU U License Class—�f-Y p
LLl Date Conlrannr APPLIANCES-RESIDENTIAL .DADDITION El PLUMBING RE-PIPE
.Mo, ARCI{I'I'E.CT:S DECLARATION El MULTI-UNIT []STRUCTURAL
z O rrr�P I umdenladd my plans shill be used as public treads PANELS MODIFICATION
OZ=fO UP TO 200 AMPS 'DTNTERIOR El CHIMNEY REPAIR
r4tm Licensed Isme."Inual 201-111(%IAMPS IMPROVEMENT
4 g x.-1 OWNER BUILDER DECLARATION
0OCC M Q 1 hereby offimt that I am exempt fmm the Contractors License Law for the OVER IpB AMPS C3 BATH RBMODEUREPAIR EIDEMOLITION
Dow U following rcasom.(Section 9031 5,Braless and Profession,Code:Any city or county SIGNS ELECTRICAL. ❑OTHER
which requires a permit to amsu'uct,alter,improve,dmnalial:,nr cpair any slmcmry Li--
)norm its issuance.alsomapi...thevpplicam toroohperudt'.file.eignedvorarem SPECIAL CIRCUIDMISC.
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
CCIO (commencing with SCc0o07001)of Division 3ofthe Businesses Professions Code)or TEMP.MPI'F.R OR POLE INST. COMMERCIAL: -
a m that he is exempt therefrom and the basis for the alleged exemption.Any violation of [INEW BLDG/ADDITION [IDEMOLITION
y ❑ IMPROVEMENT 7031.5 by any applicant for u permit subjects the applicant)a civil penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE
qZZZZ not more than fio.hundred doll.,P1500).2 Q has owner of lheprnperty,or my employees wllh wagrs as thclr salt a�mpemm�iun,” SWIMMING POOL ELECTRIC '
C will do the work,and the structure is not intended or offered for sale(Sec.91W,Business ❑OTHER
IIIand Pro(eaiunx Crile:The Conlmcm's License Law does not apply to an owner of OUTLETS-SWITCHES-F1
property who builds or improves themon,and who docs such work himself or Through
his own employees,provides that such improvements arc not intended or offered for NEW RESIDENTIAL ELECfR Q D
sale.If,however,the building or i mprovemem issold within one ye:uof complel{on,the e<;I- 5$IeT.FLOORAREA
owner-builder wl11 have the hunan of proving that ha did not had Id art improve for put. J\
pose of vole.). TOTAL:
El I,as owner of the property,am exclusively convecting with licensed contractors m
onsnucl the project(Sts.70ecL Business and Professions Code:)Me Conuactuh Li-
censeLawdoesnolapplymanownerof property who builds or impmvas thereon,and QTY, PLUMBING PERMIT FEE '
who contracts for such projects with a commctons)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
Into exempt.der Sec. ,B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owns Dam
y'f)under
Penalty
on DECL ION BACK FLOW PROTECT.DEVICE
Owner
l hereby yG{ under)sentry of perjury one of the following declarations
•❑.l have and will maintain a Certificate of Consent n self-insure for Workers Compere DRAINS-FLOOR,ROOF,AREA,COND,
svtion,as pvided for by Schon 3]101 oflhe Labor Code,for IM1c,scaft rnmuce of the STORIES TYPE CONSTRUCTION
ro
work for which this permit is issued. FIX'T'URES-PER TRAP
❑I have and will inuin Wnrkcrs Compensminn Insurance,as rcgnircd by S¢limt
3IDOaflhs La ,forliepedarnmex.fbiwankfor whit)•./.P' permit is issued. GAS-EA.SYSTEM-1 INCAOUTLETS OCC GROUT' APN
My Working it..In ranee cam r J PoI' m lr-5mis
Currier4 4 ' GAS-EA,SYSTEM OVER 4(EA) '
CERTIFIG T Ap F. EMPTIO IzR6M WORKIiNS'
)MI'IINSATION INSURANCE GREASUINDUSTIti.WASTE INTERCEPTOR BUILDING DIVISION FENS
(This section enol he completed ifthe permit is nature hundred dollars($1W) GRFASCTRAF
ar less.) PLANCITECK FEE
I ceninythm.Ne pert once beckmewubject io pee Woriss'Comer.
natemplay nny persue inu nets as became subject to he Workers'Com n- SEW HN-SANITARY-STORM EA 200 Ff.
saline l.awsof Culifo nm r o Pc ENERGY FEE
�j Applicvnt WATER HHATER WNIiN'I'/IiLECTR t V GRADING FEE
Fly NOTICE TDA ICANTVInf Tureding this crd"icsle of .xemplia ,you should WATERIVSTEM/fREA'TING
a ; become suhjccl Ir the Wr Compensation provisions of Ne Lobar Ede,you must SLIM FEE
rth
L[1 fowith comply with such provisions or this permitshall be deemed revoked. WATER SERVICE
Q
�' CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH. SQ.fel'. PAID
UO IM1erehy affirm ohm there is nconxlmetion lvnJing agency for theperformnneenf Dote Receipt#
W. H the workfmr,which Nis permit is issued(Sec.3yU,Civ.C.)
OU Lectirs Name - TOTAL:
Lenders Address TOTAL:
T cenify That I have read this...Resume and amc thanbe abrve infmmulion is BUILDING FEE
DI) comet.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FETE
V G building construction,and hereby nmhorize rcpraemmtivcs ofthis city In cater upon the SEISMIC 113E
.have-menlinnni properly for inspection purposes. PERMIT ISSUANCE
dem
(We)agree to save,indemnify ad keep harmless the City of Cupertino against ELECTRIC I BE
Iiabilides,judgments,costs and expenses which may in any way issue against said City
in
can an';'
gm ming ufthis pemtil. ALTER OR ADD TO MECH. PLUMBING FEE
APPLTC f RSTANDS AND WILL COMPLY WITH ALL NO AIR HANDLING UNIT(10 I0.000 CFM)
SOUR s E OLATI NS. MECHANICAL FEE
AIR HANDLING UNIT(OVI3R 10,0IX1 CFM) CONSTN 1 TA%
Signayrey Applicvnl/Cmuoai Dae EXHAUST HOOD(W/DUCT) HOUSING""A I FEF.
!/ HAZARDOUS MATERIALS DISCLOSURE
Will the npplicanl or fuwm building occupant store or boodle M1ar Nnus material HEATING UNIT(TO 10003 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety MCC 0
Code,Section 2.5532(a)P HEATING UNIT(OVER 100,000 BTU) �
❑Yesl ❑Nn - VENTILAq'ION FAN(SINGLE RESID) fPAlu1F
�1— Receipt#
Will the applicant or nos a building occupant B use ea Air Qu or devices which y°L'rl r pxIs
.emhhtmrdnus air contaminants as defined by the Bay Arca Air Quality Management BOILER-CONE(3HP OR 103.0011 BTU)
:
District? I TOTAL.
F7 Yes 7N BOILER-COMP(OVER 13,000 BTU) e
I have mall aznNohs mamdals requirements Ender Chapter 69 of the Culi- AIR CONDITIONER - ISSUANCE DATE
folnis Health&S Cada Sections 25505.25533 and 25534.1 undermad that if the NEW RESIDENTIAL MECH. SQ.FT. t
buildingdersm m�llylow alcrent.matuateryrcsponsihility to notify the occupant
of the
real
els whichm IMmel pri sof Cenifl moVY9P.
a
Oy noir d m Dae 'TOTAL: ISSUEU BY:
OFFICE
0,- C
10300 Torre Avenue
f Cupertino, CA 95014
Cupel'tll10 Building Division
(408)777-3228
(408) 777-3333 (fax)
September 23, 1996
Robert Lockhart
7890 Robindell Way
Cupertino, California 95014
SUBJECT Waterheater: Permit#28889
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 Clerk
•
Pm"ev on{;eae:,ed Pzue