28729 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
' CITY OF CUPERTINO BUILDING-Fl1.EC`GUCAI. PERMIT NO.
BUILDING DIVISION -APPLICATION/PERMIT PLUMBING-MECHANICAL, n O
BUILDING PROJECT IDENT'IFICA'TION G o
729
BUILDINGADD S - SANITARYNO, APPLICATI,OO.N/tSUBMI TALDNt
OlkNCS2AME: PHONE: CONTRACTORS NAME: LIC NO, , a'
NIC CONTROL M
�ARWHitIT/E I ITER: LIC NO: ADDRESS: ❑ -
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLfUUMB/MECH
❑ ❑, Ce ❑
LICENSED CONTRACIOR'S DECLARATION 'QTY. EL17CTRIC PERMIT PEE
I hereby affirm that 1 um licensed under pmviaians of Chapter 9(commencing JOB DESCRIPTION
sXZ with Section 9000)of Division 3ofthe Business and ProGssi...Code anJmy license i. RESIDENTIAL-
00 . �J PERMITISSUANCE
LL m full force m 'if Gr4� ]a i ❑SFDWL ❑KITCHEN REMODEL
�UfL]l 1.ice is pp QQlaa Lic.q APPLIANCES-RESIDENTIAL
�« Dam.Ll- Coatmcmr ❑ADDITION ❑PLUMBINGRE-PIPE
ARCHITECTS DECLARATION ❑MUISI-UNIT 0STRUCTURAL
F5N PANF.I.S
ZOrla Zj I understand my plans.stall he used its public records MODIFICATION
OZ 4O UPT0200AMPS El INTERIOR El CHIMNEY REPAIR
1.4 t"ii Licensed Professional 201-I(I(IOAMPS IMPROVEMENT
OWNER-BUILDER DECLARATION
C 6 I hereby affirm that 1 um exempt from the Contractor's License Law for the OVER cry AMPS ❑BATH REMODELIREPAIR ❑DEMOLITION
following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER'
which requires is permit to construct,alter,improve,demolish,or repair by swcture
prior to its issuance,also requires the applicant for such Permit to Elea signed statement SPECIALCIRCUIT
that he is liceasedn
pursuanolisi
he provisions of the Contmemr's license law(Chapter 9
�yo0 (commencing with Section 7")of Division 3 of the Business and Professions Code)or TEMP.MEFF. RPOLE INST. COMMERCIAL,
d y M tY that he is exempt therefrom and the basis for the alleged exemption,Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
uXi B• Section 7131.5 by any applicant for a permit subjects the apfladill to a civil penalty of POWER 62VICE5
FZY
but more than five hundred dollars($501
- []TENANT ❑FOODSERVICE
QI,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
Qa will do the work,and the structure,is ant intended or offered for sale(Sec.]ULS,Business ❑OTHER
Yl, and Professions Code:The Contractor's License Law does not apply In an owner of DO[1.I TS-SWITCHES-PI XTURES
a' properly who builds or improves thereon,and who dots such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL F.LECIR SQ IT.
sale.If,however the building(it Improvement is sold within oneyear of completion,the SQ.FT.FLOORAREA $SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for put-
proc of sale.).
❑L as owner of the property.am exclusively contracting with licensed comments to TOTAL:
construct the project(Sec.9144,Buviners and Prolusions C lc:)The Cuntrnenr's LI-
seme,Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUM PERMIT FEE
who commcts for such projects with a contractors)licensed pursuantto the Conlncnrx
Licenu Luw. PERMITISSUANCE
lam exempt under Sec. ,B&PCI'orthisreason
Owner Date ALTER-DRAIN& ATER 13A - VALUATION
WORKER'S COMP17NSATION DECLARATION BACK PLOW PROTECT.DF
hereby affirm under penally of perjury one telNe following declarations,
'•❑I have and will maintain a Certificate of Consent m selfinsure for Workers Coalition- DRAINS-FLOOR.R AREA.CON STORIES - TYPE CONSTRUCTION
cation,.s vided for by Section 3900 of rho Labor Gde,fof the performance of the
r which'his permit is issued FIXTURES-PER
❑1 have and will maintain Workers Compensation Insurence,as required by Section
3900o1fthe labor Cafe,farthe perfomurnceof the work far which on,permit is issued. GAS-FA.SYSTEM-1 INC.4 OUT, OCC GROUP APN
My Work ompens n Inst a carrierand Policy r fib t �/
Camicr: /,rI/a�s�t--�f�Iblicy No.: - �� GAS-IiA.SYSI'EM-OVER 4 WAYK sis
CERr11lAC IEOFEXEMPDONrRO WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERC
(This,onion need nm he completed If the permit Is ounce hundred doll...(Slop) BUILDING DIVISION FEES
or less.) GREASE TRAP
PLANCHECK PEIi
Loy any that inthe Performanceof
as to he work
Gewubjecuspee Workers
aris es Ciamert. SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner sn nuo become subjecnn the Workers'Compsn- ENERGY FEE
� Z inion Laws of California.Date' WATER HEATER W/VEN5EWTAL
Applicant GRADING FEE
ti NOTICE TO APPLICANT.If,after making Nis Ceuificale of Exemption,you should WATER SYSTEM/TREATI
abecome subject to the Workers Compensation previsions or the Labor Code,you must SOILS PEE
W ronhwith comply withsuch Pmvkmrsor this permit shall he deemed revoked. WATER SERVICE
Q
� z CONSTRUCTION LENDING AGENCY NEW RESIDEM'IALPLMPAID
UO l hereby attired that is a construction lending agency lar the perrntmunccnf Date Raciptk
U. (• the work for which this permit is issued(Sec.309],Civ.C.) _
U Lenders Nance IDTAL:
LTI Lender's Address
�kst 1u I rally that 1 have mad this application and slate that the above inro.edntir i is BUILDINGFEE
i--ty correct.l agree m comply with all city and county ordinances and state laws relating m QTY. MECHANICAL PERMIT FEE
U 2 M1vilding construction.and hereby euthonm repreamvtives of this cirymcater upon rhe SEISMIC FEE
.hove-mentioned property for inspection purposes. pERMI T ISSUANCE.
(We)agree In m,c,hdenmify and kceplartnless the City of Cupertino ugmusi -- CLEM RIC PEE
habiblai,judgmeres,costs and expenses which may in any way acme against said City ALTER off AUDIT)MECH.
in asequence of the granting of this pemsit. PLUMBING FEE
LA I
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO Ill,"CFM)
MECHANICALFEE -
SOURCP.REGULATIONS. � -
AIR HANDLING UNIT(OVER IL000CFM) CONSTRUCTIONTAXo a A
glgnemrc nrApplieml/Gmuactor Date EXHAUST GOOD(WIDUCT) HOUSING MI'PIOATION PEB a "d
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicaatorfuture building acupam sere nrhandle hazardous mvadal HEATING UNIT(TO 100.000 BTU) o
ns defined by the Cupcnino Municipal Code,Chaprcr 9.12,and the Health and Safety
7777N - I Ina,
Code,Section 25532(.)?. HEATING UNIT(OVER I(N�,I)WI I'Of 1
❑Yes ❑No TIPAID -
VENLAt10NPAN NGLE RFSID) Uam� IHec'l, piptN—
Wdl the applicant or farm building occuuse equipment or devices which r] f
,.if
hupantaarduus air commit as defined by the Bay Area Air Quality Mono mem NOILIiIt-CO 13HP ON 100,000 BTU) t
District? TOTAL:
my. ❑N -o' BOILERMP(OVER 100,000 BTU)
I have read the h our maenads hismicmcnts under Chapterfi.95 mile Cali. AIR CONDIT10NER ISSUANCE
.rase Health afny ode,Sections 2.55115.25533 unit 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.E4.
uildin6 Jne. curt fly havemtenem 'tit is my respnnsihllhym notify 0tearomant
trine req cots mel pdnrto"a"bee araeenifieann occa aney.
re TOTAL: ISSUED BY:
OFFICE
® 10300 Torre Avenue
Cupertino,CA 95014
Cupertino Building Division
(408)777-3333 (fax)
September 25, 1996
Homeowner
10104 Randy Lane
Cupertino, California 95014
SUBJECT Plbg permit: #28729
To Whom it may Concern:
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
Prn!hui en Pecvrmtl Pma,