28644 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
PUB,DINC.DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
IIUII.DING PR(IJRCT IDENTIFICATION
BUILDING ADDRESS: ' O/I J SANITARY NO. APPLICATION ON SUBMITTAL DATE
103 A-m-
O N R'S AME: F-e15 12 PHONE CO RA R'S NAME-Y-209 LICNO:
NIC CONTROL#
ARCHITL'CDENGINEER: LIC NO: A SS - ❑
10 /3a Ov v
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Flats Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
❑ ❑ ❑ ❑
LICENSEDCONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby at11mm that 1 am licensed under provisions of chapter 9(commencing r JOB DESCRIPTION
�� with Section 7000)of Division 3 ofthe Business and Professions Code,and my license is RESIDENTIAL
�U� in toll force and effect �/916y PERMIT ISSUANCE ❑SFDWL ❑ CHEN REMODEL
j License Glaze C� 6 LIf.X (L/(�— APPLIANCES-RESIDENTIAL ❑ADDITION PLUMBING RF.PIPE
W Dow-Contractor
Z l ARCHITIiCTS DECLARATION PANELS El MULTI-UNIT ❑ UCURAI.
O OZ 1 understand my'plans shall be used us public records MODIFICATION
UPTO 211(1 AMPS ❑INTERIOR [j CHIMNEY REPAIR
FQra Licensed Professional- 201-1000AMPS IMPROVEMENT
C OWNER-BUILDER DECLARATION OYER 10010 AMPS ❑BATH REMODELlREPAIR [I DEMOLITION
K Iy�< 1 hereby affirm Nat I am exempt from the Contactors License law far the
361V. following mason.(Section 7031 S,Businass and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
r� which requires a Fraud to construct,cher,improve,demolish,or repair any structure
<1 pnonoitaissuanor,ulsoreymresthe applicant forsuch permit m lileueigned statement SPECIAL Cl RCUIT/MISC.
ythat he is licensed pursuant to the provisions of the Contractor's License Low(Chapter 9
(commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
d that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Seem.7031.5 by any applicant for.pemmniub,cmdarapplicant 1.a civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
i, net more than five hundred dollars($50y. IMPROVEMENT
q6 ❑1,as owner of the property,or my employees wish wages as their sole compensation. SWIMMING POOL ELECTRIC
will do the work,and Nestrvcwre is not intended moffered inside(Sea 7094,Business ❑OTtt� R
4 and Professions Code:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES P tri
property who builds or improvers there ot.and who does such work himself or through
his awn employees.provided Net such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ ET.
sale.IL however,the building or improvement is sold within one year of completion,the [e �SQyFT��(QQR AREA &SQ.IT.
owner-builder will have the burden ofroming that he did not build or improve for par,
pose of alleJ.
❑ 1,as owner of the property,um exclusively eman ang with licensed contractorsm TOTAL:
construct the project(Sec.7044,Business and Professions Cars:)The Contractors Li- r Ur I,U T'C 11I Ili♦,/
cense law dons not apply to an owner of property who builds or improves Merton,andQTY. PLUMBING PERMIT FEE _
aclarm traea for arch projects with a commanrfs)licensed pursuant m the Conlmcmrs
License Law. PERMIT ISSUANCE
[II am excrnpl under Sec. B Ar P C for this reason
Owner
ALTER-DRAIN&VENT-WATER ULA) VALUATION
Daie _
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the fallowing declarations:
s C]IhavevndwillmainumaCenificatc ofConunnn sdf-insure fm Workers Compcm DRAINS-FL(R)R.ROOEARFiA,GOND. STORIES TYPE CONSTRUCTION
sound,us Provided for by Section 3700 of the Linen Code,for the a fnonare,of the
work for which this pawn is issued. FIXTURES-PER TRAP
Cl I have end will maintain Worker's Compehmtion Insurance,as required by Section
37M ofthe Labor Code,for the performance ofthe work for which this permit is issued. GAS-HA.SYS1'EM-I INC.40UTLETS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number arc: -
Carrier. Policy No.: GAS-EA.SYSTEM-OVER 4 EIA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This section lived not ho of ideled if the pemna is for one hundred dollars($1 flah GRBASHTRAI'
or less)
PLANCHF,CK PIiE
I cedi(y that in the performvnceoDhe work forwhich this permit is issued,lshall SEWER-SANITARY-STORM EA.200 Pf.
not employ any pcmn to a y ma n t hecnme subject to the Wurken'Comped- ENERGY FEF. '
o z salon a y CeJ ora am iter so u o I WATER IIHA'IP.R WNENT/ELFLTR GRADING FI?P
0 APPliwnt GLz.✓1 ...��5�/.�<.�4
f/I NOTICE TO AI'I'LIC NT:IL nflcr mukia, as", com d Esrrdainn,you should WATER SYS'fHM/1'RLATING
a become subject to the Worker's Cotnpensation provisions of the Labor Cale,you moa SOILS FEE
W Q forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ,PIL PAID
UO
I herebyvffnrm that Nem is a construction lendillo.mcy far mr,adhmmnce of Dom Receipt
fi r. the walk far which this permit is issued Bro.3097,Civ.C.)
c[!J Leoder's Name TOTAL:
Lenders Address TAI.
py I certify that 1 have nerd this application and sate that the above information is BUILDING FEE
fn correct l agree to comply with all city and county ordinances and ante laws reforms to Q,FV MECHANICAL PERMIT FEE
Up ybuilding construction,mW hereby amhonim mpmsenmmives ofthis city to enter upon the SEISMIC FEE
M14 above-mentionext property for inspection purposes. -(We)agree m save.indemnify and keep hamdess the City of Cullouno against PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgmentx,costs and expenses which may in anyway accrue against said City ALTER OR ADDTO MECH.
in consequence of the granting of Ibis prout. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINTqIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE EGUL IONS. / Jae
N AIR HANDLING UNIT(OVER I0,WIICFM) CONSTRUCTION TAX
Signature 0fA plicanUContactorHOUSING MITIGATION PHB Date EXHAUST HOOD(WIDUCT)
'HAZARDOUS MATERIALS DISCI.(}URE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(0)? HEATING UNIT(OVER 100,000 BTU)
-1 Yea 911.
VENTILATION PAN(SINGLE WISED) PAID
Am Imlpplicant or sholding occupant use eQN tat devices which
Data Reeip #WslOn conaminm ..s dfted by the Buy Are.Air Quality Mungemem BOILER-COMP(3HP OR HXEW BTU)
TOTAL:
mstrtct?C]Yes BOILER-COMP(OVER 100,000 BTU)
C�Jo
Lve read the hazardous remodels AIR CONDITIONER
regmremeno under Chapter 695 of the Cali- I$$U A
h&Safety Code,Sections 25505,25533 and 25534.1 undentand aha if the NEW RESIDENTIAL MECH. SQ.FI'.s not currently have u oc t tis my,tapmsibiliry to ntify thencenpamrttu uwhpch must ly,4hbI 'nftoissuenceofuCriHwteof0ecupancy.'Ltduthoured agent Date TOTAL: ISSUED
OFFICE
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10300 Torre Avenue
Cupertino,CA 95014
u(wec
o Building Division
(408)777-3228
(408)777-3333 (fax)
September 25, 1996
Charels Fels
10371 West Acres Drive
Cupertino, California 95014
SUBJECT Repipe, permit#28644
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
Printed 011 ROCVCtC(t RICV,