S 3065 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEIARICAL PI?HCITNO. 3065
BIJILDING DIVISION APPLICATIONA-ERMIT PLUMBING-MECHANICAL
Vl
BUILDING PROJECT'IDRNTEFTCATION
BUILDINGADDRESS SANITARY NO, APPLICATION SUBMITB'AI.DATE
OW . '$NJJA J_ 1'EIONIi: C�tI�'pt'fRACTO SNAME: J I.ICNO'
(%CF'/ 4G as;la_ -7 / rl� �QQ.SfPL �«A-<_ C/GS-S?.n? N/C CON]ROL#
.RCHI THC VENGI EER: LIC NO', ADDRESS: "� ❑
CONTACT: I'IIONIi:
BUILDING PERMIT INFO
2 ❑ Consultant Track Paid by Applicant(Initial) RI.DG F71 EC 'I.IJMB MUCH
LICENSED CON'TRACTOId'$DIiCLAR'TION ❑ ❑ ❑
I hereby all that 1 am licensed under provisions of Ch." 9(commencing Q3 Y' IiLECTRIC PERMIT FEE
SC Q Z wire Seninn]wro)n(Divisir n3 of me Basin...and Prom:inns Calc,and my lianee Is JOB DESCRIPTION
WC in full lbrcemldeffeclC+/O 5 r^/^� PERMITISSUANCE RESIDENTIAL:
aUZU -we ns�CmsLs ---F� Lic.ro J / J / ❑SFDWL Kit REMODF:I.
NQi Dal- .y�— J_�—Codrvu L APPLIANCES-RESIUEN9'IAL ❑ADDITION El PLUMBING RIsPIPF
AR CHIT he TS DECLARATION
r
y I mrsm
dcnd my phM ntS shall used public recoNPANELS ❑MULTI-UNIT ❑STRUCTURAL
oz— x MODIFICATION
UP 0200AMPS
❑ITiR10R
El CHIMNEY REPAIR l—essmnaOWNERBUILDER DECLARATION 211-I00IAMPS IMPROViMENI' El SWIMMING POOLS
UU 1 hereby affirm Thal I am exempt from the Contractors License Law for the OVER ANNE AMPS ❑BATH REMODEUREPAIR 0 DEMOLITION
31L ho owing reason.(Section]1131 t,Business and Ponesslons Code:Any city or countyall
hich routines.permild,credow ' y
nSIGNS ELECTRICAL
F.E:CQImprove. repair strucmc
' imp h applicant II II II gndstme em SPI:1AI IR SC.
A: ❑OTIIIiR
Lj
CLKLqRgd M0 To L
TI: E PIR IN OMMER JAI:
4 W e he'hes Tweli31.5 b Iherelrem and Ihe ba.+is farhects the exemp wn.Any viola ❑NEW BLDG/ADDITION ❑DEMOLITION
F. Section 7031.5 than
any appliczntforapermit subjects the applicalt " pens R yl
yZy Orn more than l f thprope dollarsyempl. ❑TENANT 11 TO()[)SIiRViCI?
�,yO ❑ I,m'Owner of the properly,or my employees with wages as Th sole mmpen SWIMM � ' LEL R IMPROVEMENT
wnl du the work,anA the su uemru is oat ln,endeJ Orn w res Trot 'ec.7044,IT ❑OTI ITS
at�m and Professions Cale:The COntaews",License Law does not en
6 3 r of OUTLET S CHI? '
prepany was nrtam ar[mprOven merean,and woo enc,octal wa reagn
his Own employees,Provided Thal such improvements are not intended or offered for NEW RP_SIUENI JAL ELFCI'R SQ 1'I`. s
sale.I L however the building or improvement is sold within one year of completion,the SQ IT.FLOOR AREA S/SO.FT.
ow
nerhuiWer will have the burden of judicial Thal he did not bund or improve for par-
pone constrict
the O
❑ ?,;IN Owner of Ihe property,am exclusively contracting with licensed crnuo, m T L:
ora W n Ibe prejecr(See.]Illi.Rosiness anJ Mofeuions GNe:)The Gmlracmra Li-
wselawnoesnorapplytoanownernlproperlywhobuildsorimproveslhercon,and QTY. PLUMBING PERMIT FEE
hoco beds fursuchprojeds withacontraaor(s)licensedpursuant mIbc Conwanr's
Licarem Law.
I] Icon exempt under Sec. ,H&P C Air this reason PERMIT ISSUANCE
DUIe ACRES-GRAIN&VENT-WATER BIA) VALUA9'ION
WORKER'S COMPENSATION DECLARATION
I hereby allinu under penally of perjury One of the following declarations BACK FLOW PROTECT.DEVICE
7C_`y_
I have and will maintain Cerilicate ofConsent m wif insure for Worker's Compen- N ) COND.
on,aS presided fur by Section 3]W of the Uhur Code.for the edormo l of the STOk I'Or wh tell this permit IN Issued. FIXTURES-PIT TRAP
have and will maintain Worker's Compensation Insurance,as required by Section
0 Ofrhe laborCOec,Tanhen,hamince of the wild,for which coir perlll le issued. GAS-EA,SYS'I'FM-I INCWorkers Compensation Insurance earlier and Policy number areier: Policy No: GAS-EA.SYSTEM-OVER 4 CA)
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE;IbHTRCEI'IOR
leo.7
(I his section need.,I(l The completedif the permit IN for I a hundred dollars
(S 1 ch GREASE'TRAP BUILDING DIVISION FEES
rr "- — ---�
I cent(y that i n the aniorounce of the work for which Ibist is i,imed,l shall PLANCHECK FEE
notcm In an y pcnnl SEWER-SANITARY-STORM EA.2W IT.
p y y person in on manner m ns I hycl m Ihe Worker'Cnmpen' E
NERGY FEF.
Ozsminn Luwsn Unle.�t] 1rOm�l3
7 NO]
][Utz �If.Aft WA'I'T?k HEATER W/VIiMf/IiLEC'1'R
NG FEIi
heram.E T PPLn,Wor .IL ager Making this Cenificme Of LobarR Code
you should WATER SYSTEM/TREATING
F "'I hands subject m Ihe Workers Compensation provisions of The Lobar Gvke,you must
ai fimhwith comply with such previsions or (shall be lkemeJ revokes. EE
� Q ��r WATER SIiRVICF,
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH. SQ.Pf.
VPO 1hefahyaffinnbuilhacirucomtmdion rending aloe,The perfamunw r( Ie Rea[ptTo
W F the work for which this permit is issued(Sec.30TO.Civ.C.)
p U Lender's Name TUTAL:
Lenders Address TOTAL:
1}+ I certify that 1 have read this application and state that the above u,ma tion in NG
VZIn coned.I agreem eanply with all city unit county ordinance,•and store lawxreletingm QTY, MECHANICAL PERMIT FEE
buildingeonsuuction.and hereby amhnrmurpraenlatives Oflhis city nramerupmmon E\
ounce-nmrnioncs properly for inspection puepu+cc
(We)agree m save,indemnify and keep hamdess me City of Cupenino again PERMIT ISSUANCE IC :P 7 0
hohilit[es,judgmenta,costs and expenses which may in any way accrue against said City e
in n+cgaence of Ne grouting of this permit. ACGiR OR ADD TO MIiCH, ING Plili
APPLICANT'UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE REGULATIONS. AIR HANDLING USE T OD 10.000CFM) NICAI.F'e'
AIR HANDLING UNIT(OVER I0,000 CFM) UCTION TAX
Signature of APplmaHAZAR O Dam EXHAUST HOLD(W/DUCE)
HAZARDOUS MATERIALS.Pa DISCLOSURE G MITIGATION F..E
WillyThe Cpertoup nofuroreipal Code,
Channmre Or handle haNWOand Safety HEATING UNI'1'ITO IIro,(XXI RTU)
as defined by The Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532m)? HEATING UNIT(OVER(IOIk(g10 it I Go
❑Yes FI No
VENTILATION FAN(SINGLE RBSID) PAID
Will the applicant or future building occupant use equipment or devices which Date Receipt N
.e haeani in,oantamial as defncd by the Bay Area Air Quality Management BOILER-COMP COUP OR IWASO BTU)
Di'mm'?
❑Yen 'TOTAL:
❑No, BOILER-COMP(OVER I00,000 RTU)
I have mad The meallous materials requirements under Chapter 6.95 Of the Cali- AIR CONDITIONER
fomim Health&Safely Code,Sections 25505,25533 and 25534.1 mcconand thou if the ISSUANCE DATE
building does not currently have a tenant that it is my responsibility to notify the occupant NEWRF_SIDEN'1'[A].MECH. SQ.F.. �/
Of the mquimnmnts which Inns,hnt
u et prior to iauance of a Cenificum(if Oca'acy. Z _ `Y Y
Owner nr uulhnrize<I agent Date TOTAL: ISSUED BY.
OFFICE
10300 Torte Avenue
CITY OF Cupertino, CA 95014
CU PEk INO Building Division
(408)777-3333 (fax)
October 28, 1999
Homeowner
20569 Blossom Lane
Cupertino, CA 95014
SUBJECT: Permit# S 3065
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 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,
CCII�TY OF CUPERTINO
Christy Akatiff, Administrative Clerk
Printed on Recycled Paper