S 0287 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILDING-ELEC`T'RICAL PI2RM IT NO.
Rry1LDING DIVISION APPLICATION/PERMIT PING PRODBING-MF:DENI UFIC S O n O 7
BUILDING PROJECT IIIBNTIF'ICA'fIIIN J G O
SANI'I'AI(V NO. API'IJCATION SUIIMI'ITAL DAI'li
' ILDINGADDRPSS, //�� 11
O CA Vi In F OL a '��'l'S►q,
NFR': MFI a PH NE: CONT ICTNO: WC /1�ZG(),NTI.a
ECT/FNGINBHR: ill CNO: ADURL. ❑ /S V71
NT - PIIDN'F: Bl1ILDING PERMIT INFO
Consultant Fees Paid by Applicant(Initial) LDC F.LEc' PL� MJiCH_
LIC HNSHDCONTRACTOR:SDECLARA'1'ION QTY. ELECTRIC PERMIT FEE
I herehy affirm Nm 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�0Z with Secllor700Bof Division 3ofine Bminessnnd Prnfecsions Cnde.and myliccmas
W p PERMIT ISSUANCti
Fly in full humanoid effect. WI. ❑KITCHIiN RIiMODIiI.
juF�3 I.icense Clans Lice APPLIANCES-RIISIDENTIAL ❑AUDITION C1 PLUMBING RE-PIPIT
FZW Dum Contractor
rn6m ❑MUI:I'-UNIT ❑STRUCPURAI.
F7N ARCHITECTS DECLARATION PANELS MODIFICA'T'ION
OZ=Z l understand myplons shall banadmiablicrecams IJI•TO 2001AMPS
❑INTERIOR ❑CHIMN17Y REPAIR
F:a0 � Liatned Professional 2014000AMPS IMPROVEMENT E]SWIMMING POOLS
.•.•1t OWNER BUILDER DECLARATIONpyliR IWOAMI'S ❑BATH RIiMODEURITAIR El DEMOLITION
I hcrchy affirm thus I ant exempt front the Contractor's License Law It,,the
O y U following reason.(Section 7031.5.Business and Professions Cole:Any airy or county SIGNS ELECTRICAL ❑OTHHR
which rcyuires u permit as eonstnct.alnr.impose,demnlidr or repair any saucmre
F'u.p;J
poor o its issuance,also requires the applicant for such permit[it file a signed statement SPECIAL CIRCUIT]MISC.
�> Nat he is licensed imemantto the provisionsofthe Contractors License Law(Ciminero
qp (commencing with Seminn]IXp)of Division3nf the Business and Professions Cndcps 1TMP.MMIR OR POLE INSI'. COMMERCIAL'
a y C that he m e.c npt therefrom and the nasi,for the ullegW enemptioa Any vinlutien er ❑NEW PLUTO�OF��DCMOLIkkON
mEl ITN.
Section 7031.5 by any applicant for a panni,nupje,ts the applicant to a civil p_nulty of 1'OWERDEVICIiS ❑'TENANT ❑E,Q015M�I^,Tn ICI:
^zy o,more than five hundred dollars($500). IMPROVEM �IurG
f � 1,as owner of the propcny,nr my employees with wages ns their sole cnmpensmian, SWIMMING PUOLELECTRIC
will da the work,and the swqure is not imcndeJ orofTered tarsale(Sec.]OW,Rasions ❑OTHER
egg and Prem.11inns Cade:The Contm ums License Law docs nal apply to an owner of OUT LETS-SWITCIIHS-FIXTORES
pmpeny who builds or improves thereon,a.d who does .In work himself or through
his own employees,provided that such Improvements are no,Intended or offered for NEW RESIDENTIAL ELECTR 'SQ Irl'.
sale.If.however.the building or improvement is sold within one year of completion.the SQ.PI'.FLOOR AREA $/SQ.PI'.
owner-builder will have the human of proving that be did not build or improve for par- O ^ O�
rT S
owner of the pmpeny,am exclusively contracting with licensed commcmn m
nelmar tiro project(Sal.7(94,Bmsine,s and Profession,Code)The Cricam"InI[,I-
came Law does not apply It)an owner of
.1-nscLawdoesnotapplytounownerof propcny who builds or improves thereon,and QTY. PLUMBING PERMIT FEE L"Q
who contracts for such projects with a contract,)licensed purman,to the CUntracuT'S E
License w. PERMIT'ISSUANCE
01. m under Sec. .R&P C for this rcaemt
r ALTER-DRAIN&VENT-WX[EjR EA) VALUATION
We'SCOMPENSATION DECLARATION BACK FLOW I'ItGI'ECT.DEVICDEVICE
ha I hereby affim under
rm under penaay of perjury one of the following orkee inns:
have and will maimaina Ccnifica,e of Consent to selGinxum for Worlern Qsmpen- DRAINS-FLOOR.RODE AREA,GOND. S'IORIFS TYPE CONSTRUCTION
satins,as provided for by Section 37M of the labor Code,far the perfamamce of the
work for which this permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maimnin Worker's Cnmpawminn lnsunmce,ns required by Section
3700ofilm Labor Cade.for the performance iflibe work ftowldoh M,perntit is issued. GAS-EA.SYS'IP?M-1 INC.0 Ull'I'hETS OCC.GROUP MEN
My Worker.Compenwban Insurance carrier and Policy number arc:
Cartier. Policy No.: GAS-EA.SYSTIiM.OVER 4 BA)
CERTIFICATE OF EXEMPTION FROM WORKERS' ORFASF/INDUS'1'RL WASTE INI'T:RCEPfOR
COMPENSATION INSURANCE BUILDING DIVISION PEIiS
This section nod nntoaompletod it permit N for one hundred dellms sIIXp GREASETRAP
toles,,) PLANCIII?CK FP I
Icenilythatintheperommanceol'fire work forwhieh Nis permitis lssucJ,Iwhnll SEWER-SANITARY-STORM F.A.21X1 FT. IFr
not employ any Everson
erson in any manner m us hme as ccosomm to the Workers Comped- ENERGYWks
Z cation Laws of California.DateWATER HEATER WNEWXI.EMIT
Applicant ` GRADING FIRE
NOTICE 10 APPLICANT,IT.after making this CeniOcam of Caemptloe,you shnnld WATER SYSI'HKIn BEATING
F become subject to[lie Worker's Compensation provisions of(he LvMn Code,you muss SOILS FET:
4x31 fnnhw„h comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
Q
7 Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMII. SQ.IT. PAID Data Re cipt p
hereby affirmthis
that there is a ad(See
lending agency for the peRmmanca of
LUT, firework Na which this permit is issued lSec.3119],Civ.Cd
O ULender's Name TOTAL:
Lenders Address
W 1 canify Nat 1 have read Nis application and state that the move infornmioo is BUILDING - ,/'
i-r y correct.I.,.[.Comply with all city and county ominances and state laws calming to QTY. MECHANICALPERMIT FEE
fJ building completion,and hefehy authrim representatives of this city m enter umm the SEISMIC FEE
ahise-mn,ioned propcny for Inspection purl.ues. PERMIT ISSUANCE
(We)I to save,indemnify and kccp handless he City orcupenium.,mata ELECTRIC IV;Ii --
liabilities,judgments,costs and expenses which may in any way name against said City ALTER OR ADD'1'0 MECH. PLUMBING THE
in consequence of Ne granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOWVOINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FEE
SOUFCW REGULATIONS.
AIR HANDLING UNIT(OVER IOIgo CFM) CONSTRUCTION TAX 1 1
g p i an Cont c Da EXHAUST GOOD(W/DUCT) HOUSING'MITIGATIO FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupant store or handle limitations rnarial HEATING UNIT(TO 100.000 BTU)
m defined by the CuNnino Municipal Code,Chapter 9,12,and the Health and Safety
Code,Searle.25532(.)7 1HIATING UNIT(OVER I00,11a)11'TO)
❑Vas ❑No VENTILATION PAN SINGLE BESIDEPAID
Data RCcciPt
Wll the applicant furore building occupant equipment car devices which
•�'t.azudous air comemii nams am defined by the Bayy Area Air Quality Management HOILER-COMI'fJHP OR IW,IXp RTU) TOT I.
- ,4 BOILER-COMP(OVER 1,10.00X1BTU)
C]Yes L]No
I have mad(be lnrdnas materials reyuiremeno under Chapter 6.95of the Cul,- AIR CONDII'IOMiN ISSUANCE
fomia Hm
ealth&Safety Code,Sections 255115,2533 and 25534,I understand that if the NEW RESIDENTIAL MECH. SQ.IT.
building docs not currently have a tenant.that i,is my responsibility to notify the occupant
of the requirements which must o met prior to itinerate of a Cenilicate of Occupancy.
Owncror.ulhomrod agent- Data A I ISSUED BY:
OFFICE
}
� �{` �� . ,�• City of Cupertino
1
10300 Torre Avenue
Cupertino,CA 95014-3255
CITY OF Telephone: (408)777-3228
U P E k1 I I A'V® FAX: (408)777-3333
BUILDING DEPARTMENT
OFFICIAL NOTIFICATION OF ADDRESS CHANGE
TO: All Agencies
FROM: City of Cupertino
DATE: February 04, 2004
r
RE: Address Update: (APN #34247-093 & 342-17-094)
�) Please note the following address change: Back in March 2000, 10707 Santa Lucia Road
was divided into two lots. The existing house (APN #342-17-093) remained 10707 Santa
Lucia Road. A new house was built on the second lot (APN #342-17-094) and was
assigned the address 10715 Santa Lucia Road. Please update your records accordingly.
The new addresses will take effect immediately. If you have any questions, please call
me at (408) 777-3246.
Sincerely,
Susan Winslow
Administrative clerk
Printed on Recycled Pew
Cl t.>. o C
Cupertino
CHANGE OF ADDRESS
REQUEST FORM
NAME (please print): gy'Y �,LZ loss l YIi
TELEPHONE NUNIBER: //.a
APN: i� ``l Z / 7
EXISTING ADDRESS: 1 U 7G nF(i
NEW ADDRESS REQUESTED:.. J 5 � A NTia L U i' to 1� C u Per v\' 0
G soiy
Requests for reassignment of addresses will be approved if consistent with the following criteria:
1. The change of address will not create confusion.
2. Only the last digit will be considered.
3. The odd/even addressing system will be maintained.
4. The change in address will not result in a public safety problem.
5. Proof of ownership and picture identification is required:
The fee for change of address is $126.00 The fee is due with this request form and will not be
refunded if request is denied.
The direct costs associated with a request to change address will be bome by ithe applicant.
Approximate review time is fifteen (15) days. If change of address is granted, the new address will
be in effect thirty days following.
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nature 1 `� zQflO , Date J�
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Prmled an Recycled Paper