29261rAPPLICANTTOFILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 29261 C
BUILDING PROJECT IDENPIFICATION L V
BUILDING ADDRESS: SANITARY NO. APPLICATION^S/UBBMFPTALDATE
(001 (itNI TED OZAGE evfoxfifwd 4otT
OWNER'S NAME:. �D PNONE:� O CONT CT R'S g&osi LICN0:1 rel, NIC COYfROLq
ARCHITECIENGINEER: LIC NO: ADDRES ^ �` ❑
b L /3
CONTACT. ate, PHONE: BUILDING PERMIT INFO
ElConsultant Fees Paid by Applicant(Initial) BLDG 'LEC'1' PLUMB MHCH
LICENSED CONTRACTOR S DECLARATION O El
1 hereby fl 1 tit t Inn licensed u de m t 1( +ns me QTY. ELECTRIC PERMIT 'FEE
p : I C1p JOB DESCRIPTION
BOZO with Section 7000)ofD 3 ofthe Business and Professions Code.and illylicense Is PERMIT ISSUANCE RESIDENTIAL'
mfullforecandeflca. ❑SFDWL ❑KITCHEN REMODEL
U License Class Lica
Q U APPLIANCES-RESIDEN71AL - DITION [I PLUMBING RE-PIPE
-
rF Q W Dam Cannanore0.
_
E Dw ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ,EISTRUCTURAL
Z O al Z 1 understand my plans shall be used as public records MODIFICATION
O2—O UP TO 200 AMPS L1 INTERIOR [I CHIMNEY REPAIR
a�f; Licensed Pafcssinnal 201-1000AMPS. IMPROVEMENT
OWNER-BUILDER DECLARATION 1 OVER 1000 AMPS L1 BATH REMODEDREPAIR (]DEMOLITION C Q I hereby affirm that I am exempt from the Comnowim s License Law for the
K d U following..am..(Seaian 7031.5.Business and professions Cude:Any ntv or nmmy SIGNS ELECTRICAL ❑OTHER
a) 2E- which requires a permit to conmua,.Icer improve:demolish,or mpair my.swctum V
prior m its issuance,also requires the applicant for such permit or file a signed smmmem SPECIAL CIRCUTOMISC.
Nat he is licensed pursuant or the provisions of the Contractors License Law(Chapter 9
1y=00 (commencing with Section 7")of Division 3 offle Business and Professions Code)or TEMP.SIFTER OR POLE INST. COMMERCIAL:
that he is exempt flerufrem and the basis for are alleged exemption.Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION +
W..y Section 70315 by any applicant for a Permit subjects theruplicant to a civil penalty of POWER DEVICES
nut more than live hundred dollars(SSIMp. ❑TENANT ❑FOODSERVICE
~S4 ❑hux owner rel the pmpeny,pr my employees wish wages as their snlc cmtpc...III n. SWIMMING FULL ELECTRIC IMPROVEMENT'
�Fowill do the k and the at t intended orofferedf :I (Sec.7614 Bu:mss ❑OTHER
W w and Profess t:C ods TI Contractors L L tl t'apply t owner of OUTLETS-SWITCHES FIXTURES 0/ •S
�'3.. property who bu Ids in npn.ndscreon andwho does such work finch or through11 -his wriernployes,Provided that such improvements are nut imendednr offered for NEW RESIDENTIAL ELEcTR 'SO Ff.
sale.](heart the building or lmprovemrm is sold within onryeaaifmsmplctiagthe - SQ FT.FLOORAREA SISQ_FT.
owner-builder will have the burden of proving that he did not build or improve for Priv /
pose oonvo. 1 ��
I,ass owner of the pml um reclusively convening with licensed contractors to
construct the project(Sec.III Business and Professions Cork,The Comis.no Li-
cense Law does not apply to an owner of pmpeny who builds or improves themon,and QT'Y. PLUMBING PERMIT FEE
whormaracoAwsuch pruje<rs wImscontraam(s)licensedpursa..l othe Comlrream,
License taw' PERM IT ISSUANCE
0 I em exempt under Sec. .B&P C for this teamn
Owner
ALTER-DRAIN&VENT-WATER(CA) - VALUATIOyty/^
Dae v`
WORKERS nderPCOh1 PF.NSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby union under pcnalry of perjury one of Ne following declarations: �1
baveend will maintain.Ccnificetcof Comm or self-insure for Wnrknt's Comprn- DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPECONSTRUCTION
sation,as provided for by Section 37M of the Labor Code,for the performance of the
work for which Wis Permit is issued. FIXTURES-PER I RAP +
❑I have and will Tuaromin Worker Comilocreation Insurance, 1 1 by ti<nren
37041f1h 1 h Cold - performance of the workfor w1 n this permit is is,w<d GAS IIA.SYSTEM-1 INC.4 OV1'I.ETS OCC.CROUP APN
Ca Wnkcrs vets. �I tlPolicy orb GAS EA.SYSTEM-OVER 4(LA)
0. TII ATF OF EXEMPTION FROM WORKERS '
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION IBES
(This section need not bcmmpleted ifthe permit is favor hundred dollars(S Bill GREASETRAP
ur less) PLANCHECK FEE �
I certifythat inthc perfvemeareafibe work for which this permit is issued,]shall SEWER-SANITARY-STORM FA.200 FT.
not employ any person in any manner so as to become subject m the Worked Camper- ENERGY FEE
O sz satran Laws of C.fm ia.DamWATER HEATER WNENTIELECTR
Z Applicata , GRADING FEE
y,NOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should WATER SYSTENVIREATING SOILS FEE
a pbecome subjeauo the Worker's Compensation provisions of the Latsor Code,you must
fonhwith comply with such provisions or this permit shrthic Memel revoked. WATER SERVICE
0(
z 1 CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.F1'. PAID
1 I hereby affirm that is mnswction lending agency for Ne performance of Date Receipt at
V •the work for which this permit is issued(Sec.3097.Civ.C.)
Lcodeh Name TOTAL:
U tenders Address TOTAL:
a1 tinnily that I have read this application and Stam that the above irk mnaion is BUILDING FEE
Vi mast.I agree ret comply with all city and county ordinances andstate laws refuting to, Q•rY. MECHANICAL PERMIT FEE
V build' g :t f u l hereby authorize f tl e ty t t p the SEISMIC FEE
obi t IPu,,Mlot,asparium pariveses PERMIT ISSUANCE
(W) rae m.s
Ba indemnify and keep hornless e City o1 C pertma I...'.st ELECTRIC FEE
liabilities.judgments,costs and expenses which may.in any way accrue against said City A LTF.R OR ADD TOMECH.
in asequence of the gmatia,of his p.it. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(Tr)10.000 cPbD MECHANICAL HE
SOURCE REGULATIONS.- 1
AIR HANDLING UNIT(OVER I0,IX10 CFM)
CONSTRUCTION TAX
Sigramm ofApplianVComr. t Dat I')
EXHAUST HOOD WDUCHOUSING h11TIGATION WE!IA"! DOES MATERIALS DISCLOSURE
Willtheapphc' of future building occupant store or handle hazardous material HEATING UNIT UTO 100.000 BTU) �y
as defined by the Cupertino Municipal Code.Chapter 9.12,add the Health and Safety
Code.Section 25532(uJ^ HEATING UNIT(OVER I00,010 RTU) - "+
❑Yez ❑Nn VENTILATION FAN(SINGLE RESID) PAID A R'ci tx
WI ll theappli<am or tenon building overpaid use equipment of devices which
t bazardoas.ir conmminims as definedlyte hBay Are.Air Quality Management BOILER-COMP(3HPOR 100,00i BOILERCOMP(OVER TAL:
rsu;8rt c! r "•. y
Q Yes ❑No - F.R IUfI,(N10 BTU) - ..yr-t!YuNo
I have rcml the hazardous tnanefirls requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomiu Heeltb&Salary Code,Sectors 25505,25533 and 25534.1 undersor I tfast for NEW RESIDENTIAL MECIL SQ.FI'.
building Odes not cutraely leave a tenant,that it is or,ce,aasibilily,,notify the oavPanl '
of the acquirements which trust be met prior m issuance of a Cenifate of(Xcupancy.
Owner nr amhorizcd
:at Dam TOTAL ISSUED BY:
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K 10300 Torre Avenue
Cupertino, CA 95014
c1 perth10 Building Division
(408)777-3228
(408)777-3333 (fax)
January 22, 1996
Homeowner
10101 United Place
Cupertino, California 95014
SUBJECT Permit: #29261
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
•