S 1915 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
ITYl CUPERTINO BUILDING-RLEC'IRICA L Pli IT NO,
'BU f.DING DIVISION APPUICATION/PERMIT PLUMBING-NJ KCHANICAL 1915
IIUILDINO I'R(IJ I?C"I'IDENI'IF'ICA'I'ION
• Iil11LDING AIlORL55: SAN[ NO. AI'I'LICATION SUnMI'ITAI.DA'IG
Ow ME NAME: PHONE. IXlNT12AC'I'OR;S NAME: ., LIC NO NIC
CONIROI.a
- CO LA r co. 3/��
CHITET/P GINEER: LIC NO: N)DR 'G; ❑
C 1
NT PHONE: BUILDING PERMIT INFO
ry ^ .�J� ❑ Consultant Fees Paid by Applicant(Initial) BLDG E E PLu MUCH
' .CENSED CONTRACT'OR'S DE QTY ELECT RIC PERMIT PEE ❑ ❑
1 hereby affirm that 1 am licensed under provisions of Chapter 9 fmmmcncing JOB DESCRIPTION
QaZ with Secnion]IXOpd Divisinn3 of the eusincs and Pmfesaions Cmle.and my license is RESIDENTIAL:
WOO PIEItMIT ISSUANCIi
F+W in full mce and t0ect, ❑SFDWL HBN RBMOUCI.
QUU License Class Lic.a APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
y G W Dam Common,
F.O y ARCHI'TECT'S DECLARATION PANELS [IMULTLUNIT [_1 STRUCTURAL
z O m z 1 understand my plupahall IN used us p tic morels MODIFICATION
Oz=O /tai UP702W Ah1P5 �. ❑INTERIOk ❑CHIMNIEY REPAIR
Liccn.wJ Professional 201-I000AMPS IMPROVEMENT 0SWIMMING POOLS
�Y
OWNER-BUILDER DECLANATION OVER 1100 AMPS 0BATHRF.MODF:UREPAIR ❑DEMOLITION
6 I hereby affirm that 1 am exempt from the Commisa is License law for the
6 U fnllowing reason,(Seclinn 7131.5,Nosiness mad Professions Gale:Any city or enunly SIGNS IEI.I'.C'I'RIC ❑OTHER
W 3 W y¢ which requires a permit to construct.alter,improve,demolish,or repair any suucmre
F�OJ prior to its issuance,also requires the applicant for such permit o file a signed smmment SPECIAL CIRC6W ISC.
that he is licensed purs.anno the posisionsoflhe Contractor's License law(Chaptar9
a Q� (moununcing with Station 200t)nfDivision2ofthe Hominess and Profcsinns Cnlc)or 'HiNIR I 5'g QQMMERCIAL'
0.q o C that he is exempt therefrom and the hmis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Ii+CI 4' Section 7031.5 b.......licart for to Permit uhkns the applicant o to civil penaltynf FN'; FVICF ❑TENANT ❑FOOD SERVICE
m nonnnrethan five hundrAidollud(5510).
z Y IMPROVEMENT
E ❑Lo not trorlhe property,k,middr,cuorarr myemployeesmuneeswimwagcsas lheir sole(S.,compensation. W I LLL 1
�(..0 will Jn the xork,and the slmcfure is not imm�drd nrnRemA for sale isle.]1004.Business - ❑OTHER
63 w
and I'rnl'anions Cook: The Conanemrs license Law does nal apply m nn owner n O ill.BP S VIES-it XTURUS
property who builds or improves thmart.and who does such work himself or than r
his own employees,provided that such impmvemertn am rat intended nr offered RESID AL IELECTR SQ F1'.
sale.IL however,the building or improvement is sold within one year
ofcot nh SQ.17.FLUOR AREA FISQ.FI.
nwmcr-builder will have tire burden of proving that he Aid not build ori e r _
of mkJ.
os owner of the property,am exclusively contracting with It, contractors to A"
maws the pmjcm(Sea.]1004.Basiness and Poicoinlm Com:)0 'o Ito LI-
nnselawdoesnmapplymanownerofpropertywhomildcorimpro Land Y. PLUMBING PERMIT FEE -
whocomnmtsfornuchProject,With a comracmr(s)licensed puhxvnntm the o'n tact.
1 at n
0Law. Jr am exempt under Sec. ,B&PC fnM1h PERMIT ISSUANCE
Din
N;I'ER-DRAIN&VENT-WATER(HA) W. N
Dale
WORKER'S COM fiNSA y on T
DECLARAION SACK FLOW PROI'CCT.DEVICE
Ihercfir o
by vlunder penalty of perjury one of the following declarations: ( V
f ihavo andwiial to, y eCeni linnumfinmenso,Cod inemctn Wmker'a Coot he
DRAINS-FLOOR,ItO(3P.AItIEA,COND' SO IP.S TYPE CONSTRUCTION
tion m provide)for by Section 3]1X1 of the labor Chale,for the perfiatnancc of the
ork for which this peril is issued. FIXTURES-ITR TRAP
Fj 1 hail and will maintain Wnivrtor ante althew Insurance,av require)by Section
3700 nfthr LaborCede,liar the perlihrmance ol'Me work lot which this permit is issued. GAS-IEA.SYSTF:M-I INCA(RITLEI'S OCC.GROUP AI'N
My Workers Compcner ion Insurance cam"and Policy number arc:
Carrier: Policy No.: GAS-FA.SYSTEM OVER 4(FA)
CIERTIFICAI'F.OP 1XFMVI'ION FROM WORKERS'
COMPENSATION INSURANCE GRFASFIINIll15TRi.WASTE INTERCEPTOR BUILDING DIVISION FEES
(I hissechionneednolhecompletWiftheperit isfmronchandroddollars(91(Xn GREASE,TRAP or Icss,l PLANCHECK PGE
I cerifymm,in the perlomunee ofhhe work forwhichihispemut isisaatd,Isholl SEWER-SANITARY-STORM F.A.201 FT.
not employ any prom.in any manner so as to become subject m the Winters'Compen- ENERGY FEE
Q ,Z .ration Lao,, fCa fmaic Dole WA'ILR HEAIInt WNENT/ELECTR GFEE'2 Applicant RAVING
In NOTICE TO APPLICANT:If,after making this Cenificme of Exemption,you should WATER SYS'I HM/IAIEATING a SOILS FEE bmomt sobje t m the Worker,Compensation provminna of the Labor Coda,you must
Iimhwion comply with such provisions or this permit shall he deenhed revoked. WATERSENVICE
] Z CONS Choat re iso cIONLENDINGAGRNCY NI3W It1ESIVIENTIAl,1'1.08, SQ,Ff. PAID U:ne
U OIhnreby anirm that mere.:atmhawanan lending agency forme perfnrancc nl. •ipta
the work for which this permit is issued X..HN1,Civ.CJ
f1. F' (renders Name IOTAL:
U� Lender's Address OTA 1,' W I ready that 1 have mad this application and state that the above information is B IL
CA corn.I agree m comply won an city oma courtly ordmames and state laws mating u. QT-Y, MECHANICAL PERMIT
Uz moldingco istruction,anJ herebyawnurize representatives ofthi.v city In caner open the S.S 1 !W.
F-t alorve-mrntinned property,fur inspection purposes. PERMITISSUANCE
(WO)agree to save,indemnify and keep harmless the City of Cupertino against ELIECTI 'p
Ilabilior,jadgmmus,colo and expenses whichmay i a any way accrue against said City ACI IBR OR ADD'10 MECH. '( VI
in omequence of the gharning of this permit. PLGMHING PEE /J
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO II,00a CPM)
SOURCE RGGULAI'IONS. MECHANICAL FF.
\-�^ AIR HANDLING UNIT(OVER I0,11LY)CFM) CONSTRUCTION TAX
Sigrummf ApplicunJCardactor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Willlneropridantor future building oecupamemmm handle hazardous material HEATING ON]'I'(TO 100,000 BTU)
i,defined by the CuFeninn Mmaicipal Cade,Clmpter'9.12,and not Health and Safety
Code,Section 25532(a)! HHAI'INC UNIT(OVER I no'dol 1 BTU)
❑Yea ON. VENTILATION VFHLATIIIN FAN(SINGI.Ii HESID) Utile eceipt p
Will the applicant or future building occupant use equipment or devices which
t emit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(31111 OR 100,800 BTU) TO
);,.c'?❑Ycc ❑Nu BOILFIt-COMP(OVER I no.0d11 BTU(
1 have read the haraNamnaLs myui
ous mremcnte under Chapter 6.95 n(mc Cali- AIR CONDITIONER ISSUANCE DATE
forma I Ictdth&Safety Cotle.Sections 25505,25533 and 25534.1 tmdeoutnd mat if the NEW RESIDENTIAL MF.CIL SQ,FT, 7-2-
77
Buildingmesnolcurren,lyhavealenant,thatnishnymxponsibililylmnmafythe Mcapano / �� D
of me mquimmcnta wM1ich mon be mef pdonn i.auancc ora Cenif ate of Occupancy.
Ownermain odzcJagem Date TOTAL: ISSCUT)BY:,n/`_/x —
OFFICE
&C,
10300 Torre Avenue
Cupertino, CA 95014
o1,
Cupertino Building Division
(408)777-3228
(408)777-3333 (fax)
February 9, 1999
Homeowner
1574 Poppy Way
Cupertino, CA 95014
SUBJECT: Permit#S1915
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, 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
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