29266 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
FGTY OP��CUPERTIN0 BUILDING-ELECTRICAL. PERMIT NO /� /�/�/�/�
BUILDING DIVISION - APPLICATION/PERMIT PLUMBING-MECHANICAL / V /6 6
BUILDING PROJECT IDENTIFICATION L �! L V V
BUILDINGADDRESS: SANITARYNO.' APPLICATION SUBMITTAL DATE
R o 1 2��t6
NER'S NAME: ' a.� PHONE: y/ CO CTOR'S NAM ' wed LIC NO: NIC CONTROL x
kRCHITECUENGINEER: LIC NOLO, ADDRESS: EEC ^ ` ❑
CONTACT. PHONE: 1+,j BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BL ELECT PLUMgI
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC I'F.RMIT FFiI? (�' \
1 hereby olBrm that I am hecmed under provisions of Chapter 9(commencing JOB DESCRIPTION
Wal withS¢tion7r)(KnofDivision 3ofthelhomessand Professions Crde,undmylicerdeis RESIDENTIAL,
O O PERMIT ISSUANCE
F- in full forte xnJ cRcs.
CSC TZ / ❑SFDWL El KITCHEN REMODEL
G V R Licenu Class Lia N
��W Dae Commnnr APPLIANCES-RESIDENTIAL ❑ADIlIT10N ❑PLUMBING RE-PIPE
Dy ARCHITECT'S DECLAR ON ElMUUTI-UNIT ❑STRUfTURAL
[F.. 1understandm I Il ba used., IT oohs PANELS
Zp!/I'7 my paste ra' � _ MODIFICATION'
02 - UP TO IN)AMPS Cl INTERIOR ❑CHIMNEY REPAIR
FQ1: LL1 Licensed Pmlessional 201-IIXM)AMPS IMPROVEMENT
CY 'q 'OWNER-BUILDER DECLARATION
2 M W I hereby affirm that 1 sn e,,empt from the Contractor's License Law teethe OVER I000 AMPS TU REMODEURHPAIR ❑DEMOLITION
3 Ott V following reason.(Section 7031.5,Business and Professions Co&Any city or county SIGNS ELECTRICAL ❑OTHER
W E" which requires a permit la conseus,ulrer,Improve,terrorist,or repair any ntmemre
priorto its l„uunee,s,oreyum,the applicator taciturn pe.iuM
a cros.ed,talment SPECIAL CIRCUIDMISC.
} that he is Recover]pursuanno m
the pvisima fthe Contmcmrs Lm icenLnw(Chiper9
(commencing wim Section 7IXM))nf Division 3 ofine Business and Prnfezainm Course)or TSMC METER OR POLO INST. COMMERCIAL:
d dx o pL that he is exempt Nerefmm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W^sn Seclion70ll,Sbyunyapplicantforapemtil,uljcasthlulpllcamtoac,vil peraay of PD WEE DEVICES ❑TF;NANT ❑FOODSERVICE
not mora than five hundred dollars($500). IMPROVEMENT
a0 I,us owner of the pmpeny,or my employees with wages as their sole comps...Bon, SWIMMING POOLE F:CTIt
will do the work,and the structure is not intended proffered for sale(Sec.70k1,Business ❑OTHER
and Professions Cade:The Contractor's License Law does not apply to an owner of DUTLE'I S-SWITC ' FI RBS
property who builds or improve,,thereon,and who does such work himself or through
his own employees,provided that such improvements are nm intended or offered far NEW RESIDENTIAL PLC&V1SQ FT.
sale.If,however,the building car improvement is sold within one year of completion,the , SQ.FT.FLOOR AREA LSQ,FT.
owner-builder will have the burden ofproving that he did not build or improve for par. P A 0 IR
potentials.).
1,as owner of the property,am exclusively contracting with licensed contractors to TOT
conswcl the project IScc.7W,Business and Professions Code:)Th,Catudi ar',Li-
acrea Law does not apply to an owner of property who huilds or improves thercon,and QTY. PL LN(! MIT PEE JAN 241996
who contracts for such projects with a contractinF)licensed pursuant to the Contractor's
License Law. PERMIT'ISSUANCE �rll Y
❑lamexsnnptunderSec. ,B&PCI'orthisreaum TiesVf' yf 1Jt'C"'INV
ALTER-DRAIN&VENT- R(P
Owner Date VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
hereby affirm under penalty of Perjury one of the following declarations:
I have and will maintain.Certificate of Consent to self-insure for Worker's Compact. DRAINS-FLOOR.ROOP,AREA,GOND. STORIES TVI'I?CONSTRUCTION
satin t,as provided for by Section 3700cf Iba Lather Coda,for the performance of the ,
work for which this permit is issued, FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Sectipn
37M of the Lobo Civil forthe performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INCA OUTLETS OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number are:
Carries Policy No, GAS-V.A.SYSTEM-OVER V(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREA51%INDUS'fkl.WASTE INTERCEPTOR
INSURANCE
fThi+section need nm be completed lflhe permit is ounce hundred dollars(MINd BUILDING DIVISRtN FETES
ar lead GREASE TRAP
'PLANCHIECK FED
Ioyany mminthe part mymnarma nero as t work for subject
Perthe W is tainted, poo-shot SEWER-SANITARY-STORM EA.200 FT.
not employ any person of any manner so as m became mbjecuo the Workers'Compen- ENERGY IEE
zZ ,stilianws pf Califpmiu.Due
� Applicant WATER IIIEATEk W/VIEN'f/ELF,CfR GRADING FEE
y NOTICE TO APPLICANT,IL after making this Certificate of Exemption, no should WgTER SYSTEMO-REA3'ING
a became subject to the Worker's Compensation provisions of the LnMr Code,you most SOILS FEE
forthwim comply wim such provisions or this permit shall be deemed invoked.
WATER SERVICE
� 0
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLAN. SQ,of. PAID
L)(:) T - ore. Receiptx
IL — the work for which this permit is is add(Side.3097,Civ.C.)
O Lender's Name TOTAL:
V Lenders Address L.
1 certify that 1 have read,his application..it also that the above information ie BUILDIN
VI c0 rmd.l agree to comply with all city and county ordinances and state lawsrelating to QTY. MECHANICAL PERMIT PEE
1` V building construction,and hereby mansion mmi,sculativesoftliti city Iomoctpnn the SEISMIC FL
P above-mentioned property far inspection purposes.1f1 PERMIT ISSUANCE 1 We)agree to save,indemnify and keep harmless me City of Cupertino against ELECTRIC FEE
limilities,jadgment,coalsand expenses which may many way marueugaiust said City ALTER OR ADD TO MIECH.
in consequence rm
of the granting of this peit. PLUMBING IEE
1[1 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON
�-POINT AIR HANDLING UNIT(TO 10.000CFM)
SOURCE \TMECHANICAL OFF
IONS. , t/'I
Al.HANDLING UNI'1'(OVER 10,000 CPM) CONSy'RUCTIONfION AX
Signature of Applicant/Contrcctor Data EXHAUST GOOD(W/DUCT) HOUSING MITIG ION FEE
MATERIALS DISCLOSURE
Will theii,licant.,for..buildingdonpim suchamivalle hamedousmaerial HEATING UNIT(TO I00.0110 BTU)
1 as defined by the Caperton Municipal Code.Chapter 9,12,and the Health and Safety
Code,Section 25532(x)? HEATING UNIT(OVER 100,000 BTU)
❑Yes []No VENTILATION PAN(SINGLE RESID) PAID
Will he applicant or(atom building by are B use Area
Air Qu or devices which
Date River x
mit hazardous air conmmin.nD as defined by are Puy Area Air Quality Management BOILER-COMP(JHP OR I00.000 BTU)
District? AL:
❑Yw 7 N BOILER-COMP(OVER 100,0 011TU)
I hove rad me hae.rdnu,meeriss reyvircnuma antler Chapmr h.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code.Sections 25505,25533 and 255311 undmiand that if the NEW RESIDENTIAL MECH. SQ.IT.
building rices not currency have u tenant, ch.is my ed of
responsibility'.to o fy vee surly. l
of me rtquies not c mminl mast a mon t,for to issuantt of a Certificate nf"Im reucy.
`y
Owner ar.umorivrd egem - Dum _ 'TOTAL:
ISSUED I3Y:..1LILYLJ
OFFICE
ac
10300 Torre Avenue
Cupertino, CA 95014
ilcuf
Cupertino Building Division
(408)777-3228
(408)777-3333 (fax)
January 22, 1996
Homeowner
903 S. Stelling Road
Cupertino, California 95014
SUBJECT Permit: #29266
Dear Homeowner:
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
0