30701 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY r
CITY OF CUPERTINOBUILDING-ELECTRICAL PERMIT NO. �j 7
BUILDING DIVISION APPLICATIONIPF,RMIT• PLUMB NO-MECHANICAL J0 r O1
WILDING PROJ]tC'1'IDFN'1'IFICA'1'If1N
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
0`7
U ER'S NAME: PHONE: CONT/Rpp�CTOR'SNAMH �tLItC�NO: c
-M✓G, I1 / ,.,57-,-,, 6�Gt /r`U es% OBJ NIC CONTROL Is
V ITECf/F.NGINEER: LIC NO: ADDRESS: ❑
O
109T7 is-h"- 61G.1G. .
oNTAC'p PHONE BUILDING PERMIT INFO
� / ❑ Consultant Fees Paidby Applicant(Initial) BLDG ELECT PLUMB MECH
(.f�!'v(.!i S3--061$ ❑ ❑ � ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT ICE
1 hereby.term that 1 am licensed under,mA,imm of Chapter 9(commencing JOB DESCRIPTION
cm)z with Section 7000)of Division 3 ofthe Business and Prob dons Gale,andmyhoeme ix RESIDENTIAL
O in full farce and effect. PERMIT ISSUANCE
aF.UU License Class Lie. ❑SFDWI. ❑KITCHEN REMODEL
NG WW Date Contractor APPLIANCES-IiCSNGNTIAL ❑ADDITION PLUMBING RE-PIPH
ARCHITECTS DECLARATIONMULTI UNIT ❑STRUCTURAL
[.. 2. PANELS' ❑MDf
Z C n4 I understand my plane sh:Jl be sued ue puM1lic records MODIFICATION
oz— UPT0200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
1-�.F7In Licensed Professional 201-1000AMPS IMPROVEMENT.
F!"I the,I i c.cautER DECLARATION OVER 1000AMPS ❑BATH REMODEIIR-PAIR []DEMOLITION,,
,
hereby uffinn that I um exempt Irmo the DECLARATION,
License law for the
igqiS5�aV following reason.(Section 7031.5.Business and Professions Codec Any city orcounty SIGNS ELECTRICAL ❑0'1'HER
tF++� E.F(comancricing
which requires a permit to construct,alter,improve,demolish,ter minor any structureprior to its issuance.also requires the applicant far such permiuolile a signed statement SPECI AL CI RCUI"1'/M ISC.
pucsuanuothepmvisionsafthac amcmr's License Ww(chapter9
W WNgwith Section 7")ofDivision 3 ofthe Business and ProfessionsCodc)or TEMP.METER OR POLE INST. COMMERCIAL:man he is exempt therefrom and the basis for me alleged exemption.Any violation of - ❑NEW BLDG/ADDITION ❑DEMOLITION
W^ Section 71315 by any appoint for ia Fermiicu
t subjects the ap,llI...oll penaltynf POWER DEVICES.
w
t more than five hundred dollars(S500).
❑TENANT OFOODSERVICE
^Q ❑ Las owner ofrbe property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the suuclum is not intended oroffemd for sole(Sec.7t W,Business ❑OTHER
end Professions Calc:The Container's lJorm o Law does on apply to an owner of OU'I'LI!TS-SWITCHES-FIXTURES
R' .. property who builds or improves thereon,and who does such..,it himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELE Q MI
xole.If.boweveq the building or improvement issold within oneyearofcompleo r,the ` SQ.FT.FLOOR AREA SISQ.FT. '
natmobuilder will have the burden of proving that he did not build or improve for pur-
pose of sale.).
❑ L as owner of the property,am exclusively contracting with licensed contractors.m 1^
construct the project(Sac.70,f4,Business and Profcvslons Code:)The Contractor,U.
mmse Law does notapply man awnero(pmpeny who builds ori mprovcs lhemmi,a IN T PEC
who contracts for such pmjects with a cormorant)licensed pursuant o the Cant
License Low. PE ' SSU CF.
❑I am cnempt under Sec. ren r `
AL - VEMi'-WATER(EA) VALUATION
Owner Date -
WORKER'SCOMPI!NSATIONDECLARATION 00[;LOW PROTECT.DEVICE
1 hereby affirms under penalty a(perjury ane of the following declarations:
I have and will maintain is Cenificate of Consent toself-imam for Workers Compen- DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPE CONSTRUCTION
Ion,as provided for by Section 37M of the Labor Code,far the performance of the
work for which this Ix,nii,Is issued FIXTURES-PER TRAP
F1 have and will maintain Worker's Compensation Insurance,as required by Section
37W surhe labor Code,for the performance of Ne work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Work or. I Policy�e'
Carrier: >>`' - u ePolicy No.: >�'VDI GAS-EA.SYSTEM-OVER 4(HA) -
CERTIFICATE OF EXP PTION FROM WORKERS'
COMPENSATIONiNSURANCE GREASEoNDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
TThlx,ecJan need not hacnmpleted ifthe permit is Intone hundred Jallars($100) 'GREASETRAP
or less) . - PLANCI3BCK PF?Ii
. Icertify and intoe lamfornamceafthc work I whicothis permit is issued,l shall SEWER-SANITARY-STORM EA.2W PT.
not employ say person in any manner so as to became s.bjccutk
o the WoCo.,.-Comn- ENERGY FEE
Z7.s sution Low,of Cullfundr.Duh, WATER HEATER W/VEN'VELECTR
Applicant GRADING FEE
res NOTICE TO APPLICANT:If,after making this Cenificsm of Exemption,you should WATER SYSI'EM/fREATING
f'+ become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS PEE
Wfonbwith comply w hb such provisions or this pumth shall be deemed revoked. WATER SERVICE?
Q
d
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FT. PAID
". p Lfar luffrmthomm,i lssued( er.3 lending agency for performanceof me RaeiptN
W F+ the work for which this permL Is issued(Sm.31n).Cl,CJ
O 1-+ Lenders Name TOTAL:
{U Lenders Address - TOT L:
It
(certify that lhave rent this application nnA.urate thus the shave information is s BUIIAIN tE
L.t W) correct l a,me to comply withal]city and county ordinances and state laws reform,to QTY. MECI IANICAL PERMIT FEE. r
U Z building commotion,and hereby uniform representatives ofthis city to enter upon the SEIS F.
► above-mentioned progeny for inspection purposes. PERMIT ISSUANCEWe)agree it)nave.Indemnify and omp Iamnlow the City of Cupertino amimt ELECTRIC,4E
liabi]ities,judgmeals,costs and eapenses which may in any way uceme againstsaid City ALTER OR ADD TO MECH.in consequence of the granting of this permit. PLUMBING :BE t
APPLICANT UNDERSTAND$,NO WILL Q1 WITH ALL NON-POINT FIR HANDLING UNIT(TO I0.00D CPM)
M
SOURCE REGU CCHANI LFEE
p AIR VIiR 10, CIM)
CONSTRUCf10, TAX
Signature al' anVCm vucnr Date EXIT S HOOF ( ) HOUSING MI'TIGA ONPEB
HAZARDOUS MAI'F.RIALS DISCLOSURE
Will the applicant or future building occupant store or handle haaadous materia] HEA 1 NIT DO 100,0000TU
as defined by the Cmpertioo Municipal Code,Chapter 9.12,and the Health and Safety Li
Cade,Seedoo 25532(al^ HBA9 NI I,f B
4911
❑Yes ❑Nm VENT( PAID
TIONI'AN(SINGLF:RFSID) Date ReeciptN
Will the applicant or furore building oceupnm use eyulpment nr Jevicas which BOILf? OMP(3HP OR IINLINN
piI hazardous air contaminants as defined by the Buy Arca Air Quality Monagenrem _ T O
.trial BOILE 1 00,000 BTIO
❑Yes [2 No
(have real the hamNous momods under Cha terfi95 of the Cdi- AIR CONDITIONER requtren p ISSUANCE DATE
fomis Health&Safety Cak,Sar 2s 255115. 3 p d 2 34.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
buildin6Ooes not n yhm� tenamnh c ho Iy the occupant L 7
nfdo she rl aieh�bonal ata is Not .iI .,n
Owner or uu/ gem Dam TOTAL: ISSUED BY:
OFFICE
10300 Torre Avenue
Cupertino,CA 95014
Cii;y of
Cupertino Building Division
(408)777-3333 (fax)
March 5, 1999
Homeowner
22630 San Juan Road
Cupertino, CA 95014
SUBJECT: Permit# 30701
Dear Property Owner:
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,
CITTY� OF CUPERTINO
Christy Akatiff, Administrative Clerk
Printed on Recycled Paper