18896 APPLICANT TO FILL IN INFORMATION WITHIN REO LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENT]FICATI ON PERMIT NUMBER
aDILD,NG CZ, . APPLICATION & PERMIT
ADDRESS o
' BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
Owry ER'S PLAN CHECK VALIDATION
NA.Cp14 QTY. ELECTRIC PERMIT FEE
�. 0 CONTRACTORS PHONE
AmE It] LOAM
10.00/1
\l. L16.No.a„�I LIGHTING F1�(TURES 10.00/1.
ronrRACTOR s Ittp3- ?A {S-H p.IJ000( -CQ PPLIANCES-RESIDENTIAL 4.00 -
ADDRESS
LO fl. PHonE 7j`I PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
uc,No. SIGNS TRANS. 3.00
ADDRESS erva. SPECIALCIRCUIT 5,00 P6PMIT{WLIOgTION
ZIP EMP.METER OR POLE INS. 20.00 LV B 1V
APPLICANTS b3•� �-FYp LJ�O MOTORS SEE FEE SCH. �� -'5 '1995
ADDRESS
S Ca $a" SERVICE CHANGE 20.00 V vL -• '
w¢ _ OF GUVEHTINO.
H
00 LICENSED CONTRACTORS DECLARATION
<U w I hereby offunt that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
y (commencing with Section 7000)of Division 3 of the Business and
a > I BLDG. ELECT. PLG. MECH.
r 7 z
Professions cod, and my license is in full force an effLcl3 ❑ - ❑ ❑
Z,i=o Lice c Class _ Lic-Num sti1 VV
H r w Date Contractor
a m f 2 BUILDING PERMIT
¢ tea OWNER-BUILDER DECLARATION
o d 0 INFORMATION
E:
; n m I hereby affirm that I am exempt from lire Contractor's License MISC.- REFER TO OR
u 0 j Law for the following reason.(Sec.7031.5,Business and Professions VALUATION $/FT.
H _ PERMIT ISSUANCE 10.
,A Code:Any city or coy my which structure,
a tune permit m construct,alter,
2 a a 0 improve,he applicant
or repair any slit tore,prior to its issuance,also ELEC.CONTE. ;LIC.NO. ELEC.
a. 0 u requires the applicant for such permit to file o signed statement that
use TOTAL PERMIT TO
w w he is licensed pursuant to the provisions of the Contractor's License
z < Law(Chapter ndProcessions(commencingwithSec' 0)o ft therefrom
ofthe
M 4 0 Business and Professions Code)or 1 1 he is a pi therefrom and QTY. PLUMBING PERMIT FEE
¢ F$ by an appl the alleged ermit Soo is the a talion foaction penally STORIES TYPE CONSTR.
F_- by any applicant fora permit esu cis $5000.licun oucivil penalty ALTER-DRAIN -WATER (EA.) 5,00
of not more than five hundred allays(45001.): '
❑ I,as owner of the pr city,or my employees HIT wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation, I do the work,and the sir eture is not
intended or offered f all (Sec. 7044, Business and rofessions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contra is License L is does not apply to a owner 01'
Properly who d5 or len ToVus t rear,and who d s ch work FIXTURES,PER TRAP 5.00 SO,FT,FLOOR AREA TOTAL ACREAGE
9himself ort ugh his own septa ,provided such pro ve-
meats are untended or fa ale.ll;h e -the doing GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
• or improv mens is e b with t r Of con n c caner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder w I have the but n f oving t t 1�ldid uild ma- BUILDING USE
prove for urpo"of INDUSTRIALWASTE INTER. 30.00 RES IND cory PB omPr
❑ I,a ow r he roPerry,am c sively attracting 'III ❑ ❑ ❑ ❑ ❑
licensed >nlra mpsithv ct(S . 7044,Busine LAWN SPRINKLERS-1 INC 5 V.B. 6.00 gssEssO $PARCEL NO.
and Profe signs :Theor's License aw does not apply
to an ow cr citys or impr es thereon,anJ who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts or such jeeinaria. licensed pursuant to
the Cont, ctoI., Lic se L . SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ Ise exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
us0n_
I, Owner Dale WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
RKERS'COMPENS ION UIiCLARATION WATER TREATING EQUIP. 5.00 t
I he
ffurn that I have certificate of consent to self-insure, ZONING ENG.SITE N0.
or a mrlific a of Workers' mpensation Insurance,or a certified
copy thereof Sec.3800, LC.).
C I'oliI ' C pant I .
E ertlfleJ hereby furnished FIRE SPRINK ENERGY T 24
Z Z ❑ erE�ed co)�y pis filled wdh t• cit r 1 n divisimt.
O Appl cm1H a13pp1V1-_uJ.�r L� 't�.. -� MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
Fy 1 ❑ lO�bgC1n PERMIT ISSUANCE 10.00 FLOOD ZONE A.LU.C.
C: ICAT F EXEMPTION FROM WORKERS'
LU COMPENSATION INSURANCE PLG.CONTE. LIC.NO, PLG, v❑ N❑ Y❑ N❑
0- Z (This section need not be completed if the permit is for one TOTAL
hundred dollars IS 100)or less.)
0 0 1 certify that in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation laws of California. BUILDING
y Date Applicant ALTER OR ADD TO MECH. .5.00
>_ DO NOTICE 1'O APPLICANT: If,alter making this Certificate of 17x
1 ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with - FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10000C-F.M.) 4,00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a COnstraetion lending agency I'or EXHAUST HOOD(WITH DUCT) • 5.00
the performance of the work for which this permit is issued iSec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's No
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMPI3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city H, enter upon oho BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
muting of this permit, MECH.CONT. LIC.NO. MECH,
fr] • � - � - TOTAL TOTAL
'
Signature at Applicant/Contractor note
OFFICE COPY
• w
Ci I.0 of 1► '
Cuperthio
10300 Torre Avenue
Cupertino, CA 95014
Building Division
(408)777-3228
Fax(408)777-3333
November 28, 1995
Resident
10225 South Blaney
Cupertino, CA 95014
Subject: 10225 South Blaney, Permit# 18896 - Electric Service Change
Dear Resident,
According to our records the above mentioned permit has never been finaled by a
• City Building Inspector. A permit is considered to be valid only six months from its
last inspection date. If your permit shows that the final inspection has been completed
please send a copy of the permit, along with this letter to 10300 Torre Avenue,
Cupertino, CA., 95014, Attention Building Department.
If your permit has not been finaled, please contact the Building Department by ,
calling (408) 777-3228, so that we may arrange to extend your permit, and schedule a
final inspection.
In an effort to control the number of expired permits, the City of Cupertino
requires a response in ten working days from your day of receipt of this letter. If we do
not hear from you, the City of Cupertino's Building Department will have no
alternative but to resolve your permit as expired and discard the records.
Thank you for your assistance.
Sincerely,
City of Cupertino
Printed on Recycled Paper
e
.. .r
�. ���
`�,��
a