S 1637 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CWTY OF CUPERTINO BUILDING-ELECTRICAL 1'E IT NO
"BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J 1637
BUILDING PROJECT IDEN'i'IFICA'CLON
IfU1LDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
I;B OP ua
,OME. W� j,� _O CONTRACroR'S NAMIi: LIC NO:
1N NIC CON'CROLp
IM CHITECT/ENGINHER: LIC NO ADDRESS: ❑
CONTACT: PHONE. BUILDING PERMIT INFO
❑ Consultant Pees Paid by Applicant(Initial) tlLUG IT PLUMB MECfI
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that l am Iiesmen under pewitions of Chapter 9(commencing JOB DESCRIPTION
WOO with Section']IXXB onavfdon 3 of the Bisl.ess mad profession,code,and my Bane t5 RESIDENTIAL:
uLOp I'IiRMI'1'ISSUANCF.
aW- 1mfalle ClassAeRmt. ❑SIsDWL El KITCHEN REMODEL.
VU hicenx Class Lic.N APPLIANCES-RESIDIP,11[A], ❑ADDI'T'ION ❑PLUMBINGREPIPE
HQLDam Commemr
F7,D ARCHITECTS DECLARATION PANIiL4 ❑MULTI-UNIT E3 STRUCTURAL
O 0 on z 1 understand my plans shall be,used as public records MODIFICATION
UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
T.4 ty�j Licensed Prnfes,innul
J
201-I0DIAMPS IMPROVEMENT EjSWIMMING POOLS
- A
OVER HXX1AMPS ❑RATH RIIDIODEUREPA1R El DEMOLITION
ce yQ RAHON
I hereby vffinn thm 1 vm exempt from Oto Cnnvnaa's License Law[nr the
a'O6 V following reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL LIMBER
' A• •w'aa+�'11�•,�
3Onje which requires u permit us construct,after,improve,demolish,car repair any structure
t� ai
v�0 Fri orm its issumm,also require,the applicant].,such pe man to Ties siawdslamment SPECIAL CIRCUIT'/MISC. �
14�" that he is limerSed pursaanl none pmvisinmsof Ole Contractor's License les.(Chapter 9
W E500 fcnmtncncing with Bemion]gNlpafDivixion3nftnc tlusinea and Pmfcxslnns Cale)nr TEMP.METER ORN al COMMERCIAL:
Ilq CC that he is exempt th efirona mad the basis for the alleged exemption.Any vinleoc n ml ❑NEW BLDG/ADDITION ❑DEMOLITION
ye�N Section 91131.5 by any applicant for a pennh subjec¢abe applicant u)a civil penalty or Ovir �LITENANT ❑FOODSERVICE
Wnos mare than five hundred dollars(S5a101. 1
Z i OTHER EMF,NT
^Q ❑ Lasowner kr and
structure
or myemntended with to
their sole cWel W I DOI .E RI
will do the work,and thusuucnnrc is not intended or n06reJ forsalcisl"I4, 4,0 _ [I OTHER
w,3 m and Professions Code"The Commcmr',License Law does nna nPply 00
m an ow
of N.'I:S- T'CHFS- X FS
pmpery who build or improves Thereon,sad who doe,such work himelr nr Thr
his.wn employees,provided than such improvements ate not intended an offeree NiND U AL IiLIiC. SQ F1'.
sale.IL however,the building or improvement is sold withinone ycmnfasmpinio., SQ. RAREA S/SQ.FU
ownervh.ilder wdl have the huNcn of proving that be dm not build or improve for p L 8 ANS,
Isn't,
or„acts
❑1,a,owner m the property,ata exelnl i%cly contracting with licensed contractor,i TOTAL: c/j.r
construct the project(Sec.9144,Business and Professions CO..,The C.aban.r',
cense law daces not apply to an owner of properly who Wilds.r!ill clemnt Will QTY. PLUMBING,PERMIT FETE rC11lllll
who contracts for such projects with a coommi da)licensed pursuant to the Contractor's
I'm
Law' PERMIT'ISSUANCE
Iran exeaapa andel 'e. ,It&I' 'nr this reason
ALTER-DRAIN&VENT-W TER(EA) VALUATION
wncr Pa
WD nd LTO BACK I1f3W PROTECT'.OE Cli 1 O OD�
Thereby affirm undo ahy.f perjury one.]the following declarations: `
I have and will maintain it Certificate of Consent mulf-insure for Worker's Cnmpen- DRAINS-FLOOR.ROUP, EA, N STORIES TVPC•CONSTRUCTION
.sation,us provided for by Section 77W of me Labor CWc,for the pi forromem of the I I
work for which thixpennit is ie.urI& FIXTURES-PERTRAP
❑ 1 have and will common Worker's Cnmpensmion insurance,as required by Section �
3l00.fthe labor Cale,funhe pedomwmecifthe work foll hi,,noit is issued. GAS-BA.SYSTIN-1 NCAOUl'LETS 4, OCC.GROUP AI'N
My Worker's Compensation Insurance carrier and Policy number are:
Carrier: Policy N., OAS-HA.SYSA EM-OVER 4(EA)
CHRI'IFICACE OF EREMITION FROM WORKERS,
COMPENSATION INSURANCE! GREASEIINDUS'1'RI,WASTE INTERCEPTOR
HULLOING DIVISION F[iR5
IThiv,cclumneed not haconaplOad if l hcpcmtit 1,hoose hundreddollms(Sign -- -
.r
less) GRIiASG TRAP PLANCIIGCK IEE
Icmify,hut in the perfor....mrof rhe wads for shicithi,permit is issued,l>hall SEWER-SANITARY-STORM EA.200 FE
non employ any persot m any mamer,n as m become sabjea m the Workers CiecK.- ENERGY FEE
z2 ,union L ims of California.Dam WATER HIHNIT E W/VONT/ELIICCR
Q Ap,brialn GRADING IEE
p.l y NOTICE TO APPI.ICANT:If,after making in,Certificate o]F.,noptioll,you.maid WATER SYSTEM,TREKI'ING
becomsu
e bject a the Worker's Compensmi.n pnwiaiom m the Labor Code,you man, SOILS FEE
111 forthwith comply with such provisions or this .it,hall be,deemed resmked WATER SERVICE
CONSTRUCTION LENDING ACIiNCY NEW RESIDENTIAL TI.MB, SQ.FC PAID
Vz I lmrehy affirm that there is a construction lending agency blithe urfmmancto Dane M
V. [-' the work for which thi,lean!,is is,llW(Sce.3097,Cl,.C.)
0 1-* Leander',Name (ITAL:
V Lender's Address TOTAL:
'y' 0. I certify that I have read this application and.nate that the above information is BUILDING FEE
r�. EA correct:l agree no comply with all city and county ordinance,and state laws relating to QTY. MECHANICAL PERMIT FEE
V,� building constmctinn,and hereby umhorice repreuntativex of this citymenm,upon the SEISMICITH
ela me-mentioned property for impecaion purpeus. PIIRMI'I'ISSUANCE
(We)agree to save,indmnnify and keep harmless the City of Cupertino against I?LI'.CfRIC FEE
Iiabilinies,judgmenax,costs and expenses which may in any way accede against said City AISERORADD'1'OMECH.
in crose,ucnce of thegmming.f the a PLUMBING PEP.
APPLICANT U ' ERSTA� sS U WILL COMPLY N'ITH AI L NON-POINT MECHANICAL ETF.
Q �Q) AIR HANDLING ON]
SOURCIi It1iGW ION
AIR HANDLING UNTC(OVI3R 10,!X111 CFM) CONSTRUCTION TAX
Sigrumre of App Dain EXHAUST 11001)(W/DUCT) I IOUSING MITIGATION FILE
HAYARDOUS MATERIALS DISCLOSURE
Will theapplicant or future Eaailiingoecupam stare or handle beeturomsmamrial HEATING UNIT CRI 100.000 RT U)
as Joined by the Cupertino Municipal Code,Chapter 9.12,and the Death and Safety _
Cale,Section 25532(a)9 HHAI INC UNIT(OVER 100,000 BTU)
❑Yes El No PAID
VIiNi'ILATION PAN(SINGi.Ii It ESiU)
Dmc Reseipall
Will ane applicant in rets a building by the
y A eauipmem.r devices which
mit iwt? air contaminants m defined by the Bay Arca Air Quality Management RUILL•R-COMP DHP OR IIp,IXp BI U)
Uixuia7 'TOTAL:
❑Ye, [INo BOILER-COMP(OVER 1011.1000 BTU)
I have rend the hacrd.ns materials raluireanal under Chuptcr 6.95 ofthe Calm AIR CONDITIONER ISSUANCE 1ATE
(oris Health&Safety Cale,Sections 25505,25533 and 25534.1 undersumd ton it rho NEW RLSIDEiNT1AL MECH. SQ.ET.
Wilding does not currently have a tenant,that It is my responsibility to notify the oca'coin
of she re,ammenu which must he naea He,It,issuance of a Certificate of Oempancy.
OwnmmimthnrimJ agent Dare TOTAL: ISSUED BY: _v
OFFICE
owitv
10300 Torre Avenue
Cupertino, CA 95014
o(,
Cupertino Building Division
(408) 777-3333 (fax)
February 9, 1999
Homeowner
1587 Poppy Way
Cupertino, CA 95014
SUBJECT: Permit#S 1637
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
Printed on Recycled Paper