29118 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO ' BUILDING-ELECTRICAL PERMITNo. ^^ ,f
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING.-MECHANICAL 9
BUILDING PROJECT IDENTIFICATION -
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
10210 I_C-6&9DAJ Ot IV to,' �22'Z qS
OWNERS NA PHONE: �� CONTRACTOR'SN LIC NO: NIC CONTROI.p
D AV
FLoziaw
RCHITECT/ENGINEER: LIC NO: AU PSS: _ t ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fecs Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
1 Lam[ . ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 herehy ummt that 1 um licensed under provision of Chapter 9(commencing JOB DESCRIPTION
WC'Z with Section 7000)orDivision 3ofthe Business and Profession Code,onJmy licensers RESIDENTIAL:
I—W,= in full force and effect. PERMIT ISSUANCE -..
SUU License Class Lic.p ❑SPDWL 0 KITCHEN REMODEL
N6a
F.Gta D've Contractor APPLIANCES-RESIDENTIAL I ❑pDDIT10N ❑PLUMBING RE-PIPE
ARCIIITECT'SUECLARATION PANELS t ❑MULTI-UNIT []STRUCTURAL
Z p N Z - I um1e61LW my blabs shall be used as vuMic records � I MODIFICATION
py.-� UPT02W AMPS j / ❑IM1TERIOR [I CHIMNEY REPAIR
LirxmacJ Pmfcsainwl 201-IOW AMPS //I } IMPROVEMENT
�S4 j OWNER-BUILDER DECLARATION OVER IOW AMPS
y tY Q 1 hereby affirm that 1 am exempt from the Contractors license Law for the OB
ATH REMODEVREPAIR ❑DEMOLITION'
x 36 F following"cavi.(Section 7031.5,Business and Profession Cole Any city or county SIGNS ELECTRICAL I ❑OTHER —�A�g�y�-/�1—�-�—�
W W,n which reyuires a permit m ronswm,alcor,improve,demolish,ur repair any sweture"
ho I vl V✓��• \(� wK-1.
FLLO5 prior to its issuance,also requires the applicant for such Permit o file a signed statement SPECIAL CIRCUI'f/MISC.
aQ� that he is licensed punuanuo Ne Pmvisium Of the Commctors License Law(Chapter 9
�"p0 (commencing withsmtion Myth)of Divi5inn3oflhe Rosiness unA Profcexiun Gsdc)or TEMP.METER OR POLE INST. COMMERCIAL:
a d c C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
W n W Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
—m ,❑TENANT ❑FOODSERVICE
not more owner
rise ft hundred dollars y employees
•F'S4 ❑ Las due work,
the property,nnnyemntended with
erialus their Sole compensation, SWIMMING I'OOLELECTRIC - IMPROVEMENT
0F. will do due and the saunure rricams nut intendede Law does but
apply oanmae, fess S ❑OTHER
43 m and Professions Cale:The Cnnwcmor License Taw does not apply to owner of. OUTLET'S-SWITCHES-FIXTURES
his Ow y who builds or improves thsuch i and who improvements
such work dedohimself through
d for
his own employees,building that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If.however the
veth burden
issoldhedid non build or improve for
SQ.FT FLOOR AREA 95Q.FT.
own
er-builder will have the buNcn of bnrving that he did not build or improve fm bur-
pose of sale.). - P..(S
01.as owner of the property,am exclusively contracting with licensed contractors to TOTAL: WY g p�
construct he project(Sec.7000,Business and Profession Cade:)The Cnnwnor's Li- DF fJ
cense Law does not apply ananuv,nc,of,ra,fry who builds orlmprovcs thereon.and, QTY, PLUMBING PERMIT FEE /1 ��
who convects for such projects with a comer m p)licensed pursuant the Contractor's N n
License law. PERMIT ISSUANCE �s ^,-,� Q�`
❑ cmpt under ,B&P C for this reason` cz / 199
MJF r
Owner ex Date ALTIiR-DRAIN&VENT-WATER(EA) -`es LVAhO/YUN
W k 'S CObIPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 briefly affirm under penalty of ochry one of the following declarations: pa,.
❑I have and will maintain a Cenificam or Consent at self-insure for Workers Comprn- DRAINS-FLOOR,rR WR
sation,m provided for by Section 37M of the Labor Cade,for the pr...... of the _ STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURE
❑1 have and will mountain Worker's Compensation Insurance,uta mquiral by Suction
37W of pre Labor Code,for the performance of the work for which this Permit is issued GAS-G.SYSTEM-I INC.4 OUTLETS - OCC.GROUT' APN
My Worker's Compensation Insurance carrier and Policy number are:
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERIIFICNI E OF EXEMPTION FROM WORKERS'
COMPENSA'ITON INSURANCE GREASrANDUSTRT.WASTE INTERCEPTOR
LS
(This rection need not be completed if the permit is forone hundreddollars TS IINp GREASE TRAP
U ) DIVISION FIs
or les.] PhANCH 'K s �y
Toy anythatinthe perlirmonro the work as
pew itisissuedlshall SEWER-SANITARY-STORM EA.2W FT.
not employ any bervm in any manner so us m become suhject m the Workcri Compcn- ENERG F
.Z Appli anw.of Culifnmia.Dam WATER HEATER WNEN VELECfR
Z
NOT(mol - G 1 3B
y NOTICE TO APPLICANT.IL after making Brix Certificate of Exemption,you should WATER SS'STIiM/1'RLATING
become subject to the Workers Compensation provision n al F.
of the Tabor Cade.you mo
forthwith comh m
only witcb provisions.,,his pcnnit shall he JccmeJ revoked. WA"TER SLRVICE
Q
7z CONSTRUCTION LENDING AGENCY NEW NF_SIDENTIALPLMB. SQ.FT PAID "
V 0 Thereby affirm that there is a<onswctiun lending agency fonhe Performance of Date Receiptp
the work for which Otis permit is issued(Sec.3097,civ.C.) Q
C) F Leader's Name - 'DOTAL:
GConder,Address T
1 certify that 1 have read this application and stare that the above information is BUILD.G FEE
"0./a const l agree m comply with all city and county ordinate,and state laws relating to QTY. MECHANICAL PERMIT FEE -
C„) ,Z building convection,and hereby authorim reprewnmuves ofthis city to enter upon the SHIS IC FEE
above-mentioned property for inspection purlwus. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELE IC FEE
judgments,costs and expenses which may id any way accrue against said City ALTER OR ADD TO MECH.
onuquenmofthcgmntingofthi,prmit... PLU 1BING FEE D
APPLICANT UNDERSTANDS AND WILL-COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,(M CFM) MECHANI FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,00)CFM) CONSTRUCTIO. TAX
Signature of Ap,1wrnt/Cem.i Date EXHAUST HOOD(WMUCD HOUSING MITIGA NFEE
HAZARIIOUS MATERIALS DISCLOSURE.
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT O'O 100.000 BTU)
as defined by the Cupertino Municipal GMs,Chapter 9.12,and the Health and Safety
Code;Serono 255.12(0)'1 HEATING UNIT(OVER 100.000 BTU) -
❑Yes ❑Nu VENTILATION FAN(SINGLE RGSID) PAID
Will the applicant or future building pccupam use equipment or devices which - Der
emit hanardoua air contaminants as it by the Buy Area Air Quality Monagencm BOILER (3HP OR W,(Nq RTU) >
TOTAL:
Districrt BOILER-COMP(OVER 100,0(10 BTU)
❑Yes ❑No
Iheve real the hazvdow material requitement.under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE I,
forma Health&Safety Cade.Seucns 25505.25533 and 25534.1 undesmnd that if the NEW RESIDENTIAL MECH. SQ.FT.
ilding Jars currently haventenan
but.that it is my msponeibility to notify the occupant
ergypia uW.n ybdorto kxuanec nfa Cerci irva of�re
TOTAL:
agent ate ISSUED BY.
n&�
OFFICE
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tir , 10300 Torre Avenue
Cupertino, CA 95014
Cupel tino Building Division
1, (408)777-3228
(408)777-3333 (fax)
• November 12, 1996
Homeowner
10210 Lebanon Drive
Cupertino, California 95014
SUBJECT Deck/Trellis: Permit#29118
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
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