26898 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO B ILDIN.-ELLCTRI AI. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL, 2
6 O 9 O
BUILDING PR05EC'1'IURN'I IFICATION G v o J v
BUILDING ADDRESS: SANITARY NO. APPPLIC,TIONSUBMITTALDATE
(�C UNIT# LOT# g�
O .R NA 1. P110NE: CONTRACTOR'S NAME: LICNO: ll��
N/C CON OR
�AR H •CTIENGINIi LIC NO: A DESS: -�/ ❑
corrrper: OG la
PHONE: ?VS fl.J17 QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
KK��JJ 77 // BLDG ELECT PLUMB MCH
PERMIT ISSUANCE ❑ ❑ El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
0az I hereby affirm shat l am licensed underprovisions of Chapter9(commencingwith
0 Section70W7 IfDivisionJ of the Business and Professions Code,and my license is in ppryp}S
a�'od Tau force and erre t.
Fyy) Weems lass Lic.X_J� UP T02W AMPS
yQy Dato ECT'S Dr OVERT AMPS
Z FV h Z
ARCHITECT'S be LTS O eLARATION OVER 1000 AMPS SQ.PT.FLOOR AREA 5lSQ.FT.
CZ`-q lundersmnd my plans shat be used as public reroMs.
Pym SIGNS ELECTRICAL.
fKL
a Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
OaFI hereby affirm that I em exempt from the Contractor's license Use for the
ox "EP 91996
W 3 v- ((oolluwing reason. ETE
n.(Section 7031.5.Business and Professions Cade:Any city or county TEMP.MR OR POLE INST. S
tch requires a permit to construct,alter,improve,demolish,or repair any structure
� >- -priunoits issuonm,elso rtquima the applicant for such pesmluo fleasignetl su¢mem POWER DEVICES
00 that he is licensed pursued to the provisions of the Convector's License Law(Chaptor 'r� 1 Lsr L.sn r—r:rr,,U
dor A(commencing with Section 7")of Division Sof the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
_y or that he is exempt herefrom and the basis for the alleged exemption.Any violation of OU9'LBTS-SWITCHES-FIXTURES
FZQ Section 7031.5 by vnyvpplicantfar.permit subjects the applicanuo.civil penalty of
momoro than Eve hundred dollars($500). NEW RESIDENTIAL ELECIRPT.
Wq ❑ I,osownerofNeRopmy,mmyemployecswiNwagnmfficirsoleco.pens.tion, STORIES TYPF:CONSTRUCTION
will do lhework,and thestrucmre isnot intended reoffered forsale(Sec.7040.Business
and Professions Code:The Convectors Lt..Law does not apply to ars owner of a
property who bu ilds or i mproves thereon,and who does such work hi mel f or through his
ownemployces,povided Natsuchimpmvemmts=notintndWmoffcredfmaele.If, OCC.GROUP RES.UNITS
however,the building or improvement is sold within one year ofcnmpletion,theowner-
builder will have the burden of proving that he did not build or improve for purpose of
sola).
❑ 1,uowneroftMpmpmy,ememlusivciyronvactingwiNlicensedcontr tomto QTY. PLUMBING PERMIT "E FLOOD ZONE APN
rostrad the project(Sec.7044,Business end Professions Code)The Convector's PERMIT ISSUANCE
License I nw does not apply toan owner of Aspen who buil ds m improves thereon,and
whoemoraets forsueb projects with acenvactor(s)licensed pursaamm the Conlmetors ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
License Law.
❑ 1 vat exempt under Sec. ,B&P C far Nis mason BACK FLAW PROTECT.DEVICP. N,,, OUTSIDE FEES
SANITARY YN
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPTp
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Iherebyaffrm Natl have acerificateofeamentto self-insure.oncertifictcof FIXTURES-PER TRAP RECEIPT
Wmkers'Compcnamion lnsueence orecmified copy Nereaf(Sec.3800,Lab CJ which PARK ME Y N
covers all empl e s and r t'. a% RECEIPT'p
GAS-6A.SYSTEM-1 INC.40UD.ETS
Policy# BUILDING DIVISION FEES
Company ( / �(- GAS-BA.SYSTEM-OVF,R4(G) - PLANCNECK FEF.
f[J Certified copy a hereby furnished.
❑ Comfired copy is filed with the city inspection division. GREASEANDUSTRL WASTE.INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be complcted lithe pemait is Insane hundred dollars($103) SEWER-SANITARY-STORM EA.200 PT. ENERGY FEE
c r)ess.)
S I cervi ry that in the performance of the work for which this permit is issued,)shall WATER HEATER W/VEM7ELECTR
not employ any person in any manner so es to become subject to the Workers' PAID
Compensation Laws of California. Date WATER SYSTEM/TREATING Das u.ipt#
t
Z Applican
Z NOTICETO APPLICANT:If.after making this CeniOcate of Lxemption,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
becamesubjecty it such roComyemvthis provisionofthelabor Code,you must
? forthwith comply with such provisions or this permit shall be damcd revoked. BUILDING '
CONSTRUCTION LENDING AGENCY SEISMIC FE
VZ I hereby affirm Natthem is a construction leading agency for Ne performance of TOTAL: ELGCTRIC FEE
O the work for which.his permit is issued(Sec.3097,Civ.CJ
Leaders Name
Or, Lender's Address QTY, MECHANICAL PERMIT FEE PLUMBING PEE
V I.I age Nat I here read Nis city
and county
and state that the above laws
relating is MECHANICAL.FEE (,(�
�
come".lassrce to comply with all city end county ordinances end sato laws relating to PERMIT ISSUANCE
�-' ta,:i buildingeo tv tim,mdl mbyauthn6nmpre nWtivaof Wscity toeatmuponthe CONSTRUCTION TAX
V Z above-mentioned property far inspection purposes. ALTER OR ADD TO MECH.
(Wa)agree to save,indemnify and keep hmmlese the City of Cupertino assessor
liabilities,judgments,costs andexpenses which may in any way acerae against nems City AIR HANDLING UNIT(TO 10,000 CFM)
in consequence of the gaming of this perosis.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of ApplicanVCommctor Date EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(T0100,000 BTU) Date Receipt Is
Will the applicant or future building Occupant store or handle horrendous materiel HEATING UNIT(OVER IW.000 BTU) L:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Ileelth and Safety
El Yea 13 No GN'17LTOTA
Code,Section 25532(e)7 VATION FAN(SINGLE RFSID)
ISSUANCE DATE
� Will the npplicantorlummbuilding occupuntuscequipmenmrdevices whichemit BOILER-COMP(3HPOR IW,gp BTU) -
��hatendous air conteardnents as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District?
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT.
1 have reed the haurdaus matedale requlmmems uMe,Chapter 6.95 of the
Celifomia Ilemth&Safmy CWe,Sections 25505.25533 and 25534. 1 understand that
'�ifthe building cases not currently hove a tenant,that it is my responsibility to notify the
cuP 'vement1 which must be met prior to issuance of a Certificate of
a �'Y �x.Cep f-G�9te
Own oramharinni ton Dam TOTAL: ISSUED BY:
OFFIC
• 10300 Torre Avenue
Ci
Gte o1 1Cupertino,CA 95014
Cupel- thio Buildine Division
(408)777-3228
(408)777-3333 (fax)
March 24, 1997
`t
Homeowner
21721 Columbus Avenue
Cupertino, CA 95014
SUBJECT Permit#26898
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, the subject permit has not been fmaled. 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
9
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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