S 2120 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDUSG-ELECTRICAL PC: ITNO ^1
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 2120
)
Rt)il.DDSG PROJF.Cr IDEN'TIF'ICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION Sl1RMITTAL DATE
q 3C� I t � C� -2-q.9
OWNER.","[:AWL t .1efl%A i' 'F:. TH O "NAME LIC NO:
p A-a� ark
`, I,,,re NIC CONTROL#
CHITEEnEN 1 E J,� �JLIC NO: ADD iSS: )W ) UfV ❑
CONTACT: PHONE jBUILDING PERMIT INFO
(
I �f E] Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
( ` ( ❑ ❑ ❑ L�
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm Cat I oro licensed under pn skiom of Chapter 9(summoning JOB DESCRIPTION
"Z wim seminn]OWlofnmiaian3o0he Brrshiess and profession,Coiamid my license's RESIDENTIAL:
W O PERMIT ISSUANCE
�w= in full forte and cRD 2/ �4y9J� ❑SFDWL ❑KITCHEN REMODEL
a UO License Cl... IVIG Lic.N APPLIANCES-RHSIDENt'IAL []ADDITION []PLUMBING RE.PIPE
i-Z Ri Dave Contractor
C vs6a ❑MULTI-UNIT []STRUCTURALg.O trs ARCHITECTS DECLARATION PANELS
Z p.Z I understand my plana shall M used as public records MODIFICATION
OZ4OUPT020d AMPS El INTERIOR ❑CHIMNEY REPAIR
F 4 Licensed Professional 3111-1000AMPS IMPROVEMENT ❑SWIMMING POOIS
C x W 6 I hereby affirm ha N am exemptiR DECLARATIONCaunrs License Law far the OVER Big)AMPS L)BATH kEMODF.flR1ePAIR 0 DE LIT] L
i�qL�5 0 4 U Billowing reason.(Section]1131.5,Business and Podesmons Code:Any city nr rummy SIGNS ELECTRICAL ❑(yIHER f�
.W 3�H which requires a permil to construct,alter,improve,demolish,or repair any swemre �' `�
F'M prior to its issuance.also requires the applicant for such permit m file a signed statement SPIlCIALCIRCUIT/MISC.
AMy j••l that he in licensed pursunnno the pramvinns of the Comrnctar'v Licanxu L.,(Chupter 9
yp0 (commencing with Section WNMDof Division 3 of the Business and Professions Code)or TEMP.ME'1'ER OR POLE INST.. COMMERCIAL,
IL%o K that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
4•
Section 7031.5 byuny applicant fora pentaneakleetslhcapplicanno o civil pen:Jtyof POWER DEVICE s/^ El TENANT ❑FOODSERVICE;
me mo no than rive hundred delta,,($500) 1 t IMPROVEMENT
=f 01,as owner of the protony,or my employees with wages as theirssde compensation. SWIMMING ddi0RR:y ❑OTHER
will Jo the work,and theammureisnrn inrended nr offered for sale(Sec.7014.Boniness
W and Professions Ctde:no Contractor License Law does not apply to an owner of OUTLETS-SW CIICS�I.IKTURES , I�
�• property who builds or improves thereon,and who does such work himself or through -
his own employees,provided that such impmeements am not intended or offered far NEW RESIDIiNT1A1,GLECfIi
sale.If,haweve,the haildinger improvement iswld withinane yonrnfcomplerion,the S PT.F100R AREA S/SQ.IT
ovowr will have the burden of proving the he did nm build or Improve I'or par-
El
I,as owner of the property,um exclusively contracting with licensed contractors m TOTAL
contracting
rostrad d es had+(Secapply
]fano Busowner
and property
%no bub ds or i'iis,Conuoaors Li
sense Law does such plre tountar acrpmperty whosedJsnrimproves Conlon,add QTg PLUMBING PERMIT FEE ^n
License ,bw.for such pmjens wiC acnmmnons)IicenseJ pursuannothe Comrncmrs Y�
7 l oa Luw. PERMIT ISSUANCE? Y'
❑1 am exempt unJer Sec. .B&I'L'for this,cusnn
ALTER-DRAIN&VENO'-WATER(EA) VA UATION
Owner Date p
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE L
I herchy affimr unJer penally of perJury ane of the following declarminns:
I have and will maintain o Certifiene of C...cut....for Wt,,ker,Compen- DRAINS-FLOOR,ROOR AREA,COND. STORIES TYPE CONSTRUCTION
sntion,as provided for by Section 3700 of the Labor Code,far the performance of the
work for which this tensul is Issued. FIXTURES-PER I RAP
1 have and will maintain Workers Compensation Insurance,as required by Section
37W of the Labor Cade,for the performance of the work for which this Pearn is issued GAS-EA.SYSTEM. INC.4 OUTLETS / OCC.GROUP APN
My War oro - Insumnc carrier and Policy glwMs,afa> u(4_3 GAS-EA.SYSTEM-OVER 4(EA)
Carrier. Policy No.:3X 1 I[. O
CERTIFlCATC OF E%:MITION FROM WORKERS' GRIiASUINDUSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE ILUING DIVISION Ft
(nssection need not hccompleled ifthe permit is for one hundreddolim,($10() GREASETRAP
or les'.) PLANC 'K FE
Iccrifyout in the performance of Ce walk far which this permit is issued,[,hall SEWER-SANITARY-STORM EA.200 F.
not employ any pets any mamtt
on in nner so as to became hjeco We Workers''Compen- .N FEE
0 z sntion Laws of Califomia.Dae WATER HEATER WNENTMLECTR Y GRAI P
Q Applicant
pJ
NOTICE DO APPLICANT.If after making this Curtiriwte of Exemption,you should WATER SYS'I'EMT KEATING SOIL S FEE
1'a become a ildood t the Workers C........am provisions of the Labor Cade,you must
{0. forthwith comply with such proviomei r this permit shall Is,dremed revoked. WATER SERVICE
/ zCONSTRUCTION LENDING A617NCY NEW RESIDENUALPLMe. SO IT. PAI
me re
V O I hereby affirm tem there is a commotion lending agency for the performance of t b
LIs E-1 the work for which Cin permit uissued(Sea 3(19],Civ.C.)
U Lender's Name 'TOTAL:
HJ Unllax Address OTA L:
I codify that I have read this application and state that the above information is BUILDING FEE.
F Vt c„reel,l ogre ,acm,ply with mldnyand taatmyordlnance, ad ond,lawsmhaing to QTY. MECHANICAL PERMIT FEE SEISMIC FEE
L) z building rotenrucimm.and hereby authorize representatives of Cis oitym enter a,.the
r above-mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC FER
(We)agree msave,indemnify and keep handless the City of Cupcttina against
liabilitics,judgments,costs and expenses which may in any way accrue against said City AGfERORADDIOMECR PLUMBING FEE O
in emboss once of the gmnting of this permit. �n
APPLICANT UNDERSTANDS AND .COMPLY WITH ALL NON-POINT AIR HANDLING Ulsi rITO io,gfo all) MF.CHANICAI.FEE y
SOURCE :GUIONS Q
2 l� AIR HANDLING UNIT(OVER 10,0011 CFM) CONSTRUCTION TAX
nmr fApplicmt/Contiacmr Date (� 17XHAUS'I'llOOD(W/DUCT) HOUSING MI LCIATION FEE
HAZARDOUS MKIERIALS LOSURE
Will the applicant or future building revertant store or handle hazardous material HEATING UNIT(TO 100,0011 BTU)
as defined by the Cupertino Municipal Cole.Chapter 9.12,and the Health and Safety
Code,Notion 25532(.)^. EATING UNIT(OVER 100)(m)BTM
El Yes ❑No VENTILATION FAN(SINGLE RESIDE PAIDDa ,
m Recent
'f Will the applicant o,future building oacolom axe cgnipmea or devices which BOILBR-COMPQHPOR 100.0001HU)
tit hazardous air contaminants as defined by the Bay Area Air Quality Management 'OTA
ldnd❑Yes E]No BOILER-COMP(OVER 100.(100 BTU) ,n
I have read the hazardous materials requirements under Chapter 6.95 of the Cali AIR CONDI'T'IONER (J I/S-SyUANCE DATE
forem Health&Safety Cade,Sections 25505,25533 and 25534.I understand that if me NEW RU5I DENTAL MECH. SQ.IT
huddingdr�cs act cumenly have.tenant that it is my respnnsibinry m nofdy the occupant ll L l riff///
L
the requirements which must be met poor to issuance of a Certificate of Occupancy.
Owner or memozed a gent Umc TO L: ISSUCD BY:
OFFICE
&- clix
10300 Torre Avenue
Cupertino,CA 95014
of
Cupertiuo Building Division
L' (408)777-3228
(408)777-3333 (fax)
February 9, 1999
Homeowner
930 Liberty Court
Cupertino, CA 95014
SUBJECT: Permit#52120
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
2 �2�j
Christy Akatiff, Administrative Clerk
Par;etl on Pec�,cled Paper