27539 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO �NuTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 27539
BUILDING PROJF.CI'[DEN'rIF'ICA'I'ION'
BUILDING ADDRESS: SANITARYNO. APPLICATION SUBMITTAL MM
UNRp - LOT, / �// Or
iRS NAMI^ Pf N`52— CO 'CTOR'S NA LIC ILO C/ Y/
- C / NIC CONTROL p
•ARCIB IRCOE GINEER: LIC NO: A SS: /� �s _ ❑
n ✓.1/
CONTACT: PHONE: V _ BUILDING PERMIT INFO
QTY.. ELECTRIC PERMIT FEE
N /� BLDG ELECT PLUMB MECH
.( `J,���I/ 152"L / PERMIT ISSUANCE El
LICENSED CONTRACTOR'S
pCZ DARATION APPLIANCES-RESIDENTIAL
HomethafinoNChpmr9(commencing
with JOB�MRIPHON
Prolessi Codi andmy licerneis Lm PANELSfull force and \Pi14WLiccnu ClassLc.pIIP T0209 AMPS Lr
w<y Dam Contmcto Ill 201-1000 AMPS
70'z ARCIIITE. SD. A' fN OVER IOOOAMPS SQ.Ff.FLOOR AREA $/SQ.Fr.
66—
O/_p Iowdemund my,lans,hvll be users,publienrewds.
P y H w SIGNS ELECTRICAL
<y$j Licensed Professional
�zw< OWNERILDERDECLA TION SPECIAL CIRCUCEIMISC.
KOaF I hereby affirm Nat m exempt from th on ernes License Law for the
W following reason.IS n7031.5,Bmiressand Professio Code:Any city or county TEMP.METER OR MLE INST.
F I�Og which re,mms noir to cannmet,ober,impmve,ramulus orrepair any mucturt
zw Q2 pnormits' ance,also requires the applicant for such Permit aslgnedsmmmeat POWER DEVICES
,Mp O that s licensed pursuant to the Provisions of the Contractors Li se Law(Chnpmr
S.n K commencing with Section]000of Division 3°fthe BusinmandRass ns Code SWIMMING POOL ELECTRIC
VALUATION
m—rn r that he is exempt herefrom and the basis for the alleged exemption An violation of
p—.ZY tion 703 L5 by any app lis 9t tura scmmit,ubjecrs the applicannnecivi nahy of OUTLETS-SWITCHES-FIXTURES
tot marc than Ev,M1undred lollms !0). NLW RESIDENTIAL E•LECIR S Pf.
KFo Lus nwnemDhe pro Y. Y ployeeswiN wage t Iecon, erten, O' STORIES TYPECONSTRUCTION
M' 'lido the ork.andthea t menemororfe a( s I 5O ]04J Bus ass
I Profen. a vectors Li w J t r
pn ry b'I ° mermn, ds a hwt khi clfonM1rough his OCC.GROUP RES.UNITS
rowamp ieJ Nu mouren ,rnffe,cdf...le.If,
how ver.th dingori� issm withinoneye o'completion,the owner- TOTAL:
huih'Tw011xe the burde f ng that he did no ddmimpmve for purpose or
sale.)
❑ ecrolthepro,eny.amesclusivel marctingwimlicenswcontmemrsm QTY. PLUMBINGPERMIT FEE FLOOD ZONE ARNcore t the project(Sex.TOI4,Busime and Professions Coee:)The Convector's
License wdo,s not apply to anowne property who builds in improvesthemm.and PERMIT ISSUANCE
whocnnt etsforsueliprojatswit cvmractons)Ilecnsed p.mumno the Conmaemts
Liccm,L . ALTER-DRAIN&VENT-WATER(FA) FEE SUMMARY
❑ I am c •m,t under B&P C fm Nis season BACK FLOW PROTECT.DEVICE OUTSIDI:FRES
SANITARY Y N
Owner Date RECF.IPrp
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOL TAX Y N
❑ 1 herebyalfirm that l have acenificateofemisem m.ulf-imem,.recenifeme of FIXTURES-PBR TRAP RIiCE1Pfp
Workers'Cmnpensmion Insurance o_rvicertificA copythereof(Sec.3gW.Leb C.)whi<h PARK FEE YN
'everxallc nv E_r` JqO/ DIVISION
Poli, a I GAS-EA.SYSTEM- INC.4 OUTLETS
Y BUILDING DIVISION FRES
GmmpanY4 GAS-EA.SYSTIiM-OVER41(iAt FEE PLANCHECK
❑ Cetfie cape rshemytom11 ed.
ElCeniliedcupyisfledwit l city inspection division. GREASFYINDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
('flux section n„d not be completed ifthe permit is forest,hundrtddollars($IW) SEWER-SANITARY-STORM FA.2WFr, ENERGYFBE
or less.)
I certify that in me pskoonance either work for which this permit is issued,l shallATER HEATER ENT/ELECTR
nm employ any person in any manner so as to become whiter in the Worker' PAID
O z CAompensation"wsof Califomia. Date WATER SYSTEM/rREATING Dore Receiptb
Applicant
z C) NOTICE TO APPLICANT:If,after making this Carifewe of Exemption,you should NEW RESIDENTIAL PLMB. SO.FT. TOTAL:
f~ ry become subject m the Worker's Compensation provisions of the Labor Code,you must
� 5: fonhvah comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
LTJ D CONSTRUCTION LENDING AGENCY SEISMIC ME
•a z 1 hereby affirm mat then is a conxvuctioa landing agency for the pimfor mance of
U O the work for which mia permit is issued(Sec.3097.Civ.C.) TOTAL: ELECTRIC FEE
L.endcrs Name
0F Lenders Addmxs QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U 1 ceniry that I have road this application and state that the above information in
emrecx. l agree to comply with all city and county ordinances and state laws relating in PERMITISSUANCE MECHANICAL FEE
building construction,and hereby amhorim repreunmtivesa(this city to enter upon me
U Z above-mentioned propwy for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agrte m save,indemnify and keep harmless the City of Cupenino againw'
liabiIfies.judgmen¢,costs and expenses which may in any way accrue aguinsmid City AIR HANDLING UNIT(TO M."CFM)
c Luc f ha gran ng of t pe t.
AIR HANDLING UNIT(OVER 10,009 CFM)
wmre ofA oicamUContractor d` 'p EXIIAUST HOOD(W/DUCI'1
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 109,000 BTU) Date Receipt g
Will the summon err furor,building occupant store or handle havardous material
as defined by the Common Municipal Code,Cnapmr 9.12,and be Health and Safety HEATING UNIT(OVER 1W,000 BI U) TOTAL:
Calc.Section 25532(a)?
❑Yes 0 N VENTILATION FAN(SING LE RESID)
BOILER-COMP(3HPOR IW,0008TU) ISSUANCE DATE
Will the vpplicanmrtuture buildingm�cupant useeyui,menmrdevices which emit• {{kk hu"ammus air cormorants as defined by the Bay Area Air Quality Management BOILER-COME(OVER 109,00)Brut P A i
District?
❑Yee ❑No NEW RESIDENTIAL MECH. SQ.Fp.
I have read the ho,wilm,materials nmuiremems under Chapter 6.95 of the FEB 16 1995
Califomia Heahh&Selby Code Sections 25505,25533 and 25534. I understand that
if the building does not currently have a tenant,that it is my responsibility to notify the (s
occupant mf eche maimiC neots which must he met prior to ismance of a Certificare of CI I 1 is
Ow np•mcy.
Owner m authoriuA agent Dam TOTAL: ISSUED BY:
OFFICE-
4{•
(.Illv ll ,
Cupertino
10300 Torre Avenue
Cupertino,CA 95014
Building Division
(408)777-3228
Fax(408)777-3333
November 29, 1995
Ronald Vandenberg
21619 Edward Way
Cupertino, CA 95014
Subject: 21619 Edward Way, Permit# 27539 - Waterheater
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.
I 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
•
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