27753 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - r PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDE.N"1'IFICA'I'1(IN 5 J V
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMTITALDAT
1 UNIT# LOT# 0) ��0C
O NER NAME: PHONE: CONTRACT'OR'S • E: LIC NO:C—/O `
/ NIC CONTROL#
�IRCHITECT/ENGINE' : LIC NO: ADDRESS: r ❑
CONTACT: ^ PHONE: /
�./_ ,f/r � � QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
PERMIT ISSUANCE BLDG ELECT PLIF UMB MF'❑CH
LICENSED CONTRACTOR'SDECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Matz 00 I hereby 700L.Ifismthat r'3 ofili mud i n ss and fvmfcs of Chapter and mmencing wirb
=W— SeninnT(XI0)of Divisinn3of the Business and Prnfesxinns Code,and my license is in PANELS � \ ��' r
W�. Poll force and eIfec. [[�� ;-y- �
Q GU,pUj License�l�as '—� Lic.p? /GOn n 11P T0200 AMPS too
vFijy Date Contacor t�ffr Pte_ �, 2oT-T000AMPS
ZOyZ ARCHITECTSDECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA 3/SQ.FT.
O Z 4 0 I understand my plans shall be used as public records.
F-'�_s I_W SIGNS ELECTRICAL
C �J Livemed Professional
zsQ OWNER.BUILDER DECLARATION SPECIAL CTRCUIT/MISC.
K06o, I hereby affirm That I am exempt from the Contractor'sCo License Low for the
31+-rFit following reason.(Section construct,
Business sad Professions Cade:Any city or wunry TEMP.METER OR POLE INST.
o,ON; which requires a permit In eonsvuct,otter,improve,demolish,or repair my swewrc
��}� prior toils issuance,alsorequhes Neapplicamforsuch permit to file asignM statement POWER DEVICES
,Ep that he is licensed onar m to the provisiar,of the Contractor's License Law(Chapter
a,cX 9(commencing with Section 9000 of Division 3 offlc Business and Professions Code) SWIMMING POOL ELECTRIC V LUATION
u1_rn
,,,but he is escang therefrommdlhe basis fnrthe alleged exemption.Anyviolmmm of
F z Q -SWITCHES-FIXTURES ��Section]031.5 bynyapplcant foraprit subjects the dwito oa civilpesalt,of OUTLETS
not more than rise hundred dollars(S5010).
C o ❑ I.osawnerofthepmp rry.orm em to aswithw NEW RFSIDENTIALELECTR _SQ.FT.
Y P Y ages ere theirsolecemperwdon, STORIES TYPE CONSTRUCI'IOI
I
340 will do the work.snd the structure is not imeadeeorofrercd forme(see.➢)44,Business
send Professions Calc:The Cnntmmor's License Law doss not apply to an owner of
property vO a bui Ids m i mproveathereon,and who d«s such weak himsel for through his
employees,provided that such improvemenBarenot intendWoroffued larvae.If. OCC GROUP RES.UNITS
however.the building or improvement is said within one ycarofcompletion,streamer-
builder will have the burden of proving that he did not build or improve for purpose of T
sale.).
❑ I,asownerofthe property,am exclusively contracting with licenced contractors to QTY. PLUMBING PERMIT FEE FLOODZONE APN
answer the project(Sec.7044,Business and Pronsions Cak:)The Contractor's
License Lawdoiam apply to an awnerofpropetty whobuilds«improvesthcrcon,and PERMIT ISSUANCE
who contracts I'oasuch projects with a coname m(s)licensed pursuantmihe Contractor's
License Law. ALTER-DRAIN&VIr.NT-WATER(EA) FEE SUMMARY
❑ 1 ton exempt unser Scc. ,B&P C for this reawn BACK FLOW PROTECT.DEVICE OUTSIDE RTES
Owner Dam SANITARY YN
WORKMAN COMPENSATION DECLARATION DRAINS-FLOR OROOF,AREA.C 'D. RECEIPfp
SCHOOLR'AX YN_
I�Ihcreby affirm thatl haveuceninwte of cmrocm mself-insure,orncenifcaa of FIXTURES-PER TRAP RECEIPT'#
Workers Compensationlnsuanceorecenified copy thermf(Sa.3800,1ab C.)which KFEE Y__N
covers
rte ee t
Policyp a rs 20 GAS-EA.SYSTEM-1 INC.4 OUTLETS � RECEI N
Company L�Q#-fie O BUILDING DIVISI NFf:LS
❑ CenifieJ co hereby famish GAS-EA.SYSTEM-OVER 4(EA) IANCHECK FEE
py is
Certified copy is Glad with the city inspection division. GREASFANDUSTRL WASTE INTERCEPTOR
__ G GFTE
�./
CERTIFICATEPE COMPENSATION
EXEMPTION SUFROM N WORKERS' GREASETRAP 'g
COMPENSATION INSURANCE
This acti«need not be completed ifthe permit is future hundred do]].(SIM) SEWER-SANITARY-STORM EA.2MFT. ENERGY FEF.
les")
I«nify that in the performance ofthe work for which this Finish is issued,l shall WATER HEATER W/VIiNT/ELECTR
nor employ any person i any man to bac�95 gypject to rhe Workers PAID
z Comp pari RC farms 2-2f-7 WATER SYSTEM[HEATING Dam Recciplq
O Applicant�" o-�
z0 NOTICET A 1ICANT:ILaflermAing this Cenificateof Excmptiomyou should NEW REMDENTIAL PWIL SQ.FT. TOTAL:
becoe msubject the Worker's Compen.sam n provisions of the labor Care,you must
forthwith comply with such provisions or this permit shall h<d«med revoked.
C4 7 BUILDING IEE
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I herebY affirm that there is a construction braiding agency for the performance of
U O he work for which this permit is issued(See.3097,Civ.C.) TOTAL: ELECTRIC FEE
lender's Nunn
0 U Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I certify that I have mad this application and state rM1 Ne above information is
lL ennem.Ixgrce mcomply with all city ane wunry oNinances and caro laws reletingm PERMIT ISSUANCE MECHANICAL HE
building construction,and hereby authmim<aprtuntatives of this city roamer upon the
Ualcove-mentioned m,.y for i
pnspection pts CT ION TAX
z Wit)agrees, posts. AL ER OR ADD TO MECH_ CONSTRU
gree m snvc,' dcmnify and k vmlus the City of Cupcnino against
liabilities' cots,Crand expenus try way same against said City AIR HANDLING UNIT(TO 10.000 CFM)
in a c r(the anting of this
2 AIR HANDLING UNIT(OVER 10,000 CFM)
grld..a pphavaWo o or Date EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam Receipt#
Will the applicant or future building occupant score or handle hazardous material
as defined by the Cullom Municipal Coda Chapter 9.12,and the Health sand Safety HEATING UNIT(OVER 10#000 BTU) TOTAL:
Care,Seedan 25532(x)?
❑Yes 9.1go VENTILATION FAN(SINGLE RESID) aias�
Will rheapplicantm future buildin y p BOILER-COMP(3HP OR 100,000 BTU r,.ISSpAYNCbDATE
gby the Bay tri memouality Management ) P 4�
aaMoua air rnmaminant as defined by the Bay Arca Air Quality Management BOILF,R-COMP(OVER 100,000 BTU)
Oislrict? gFp�..� 1 'I
Lbuilding
Yes -p}tJo NEW RESIDENTIAL MECH. SQ.FI', • EB Z 11995
read the haaardeas materials requiremems underChapter 6.95 of the (+allh&Sony Code.Sections 25505,25533 and 25534. 1 understand that /s�'� Uf U tHge«snot curtently haveamnant,thm it is my asponaibility to notify the V (Jthe requirements which must he met prior to issuance ofo Certificate ohorved agcar Date
TOTAL: ISSUED BY:
OFFICE
f®" 10300 Torre Avenue
• Cupertino, CA 95014
Cil. of
c tper "1]1.O Building Division
(408)777-3228
(408)777-3333 (fax)
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
--I have and will maintain a certificate of consent to self insure for worker's compensation,
as provided for
--1 have and will maintain workers' compensation, as required by section 3700 of the
Labor Code, for the performance of the work for which this permit issued. My workers'
compensation insurance carrier and policy number are;,?6JC—
(this section need not be completed if the permit is for s Ioo.00"I=)
• --I certify that in the performance of the work for which this permit is issued, I shall not
employ any person in any manner so at to become subject to the rkers' compensation
provisions of Section 3700 of the Labor Code, I�a w' omply e
provisions. Daft -9r— Applicafit
by Section 3700 of the Labor Code for the perform nue of the wok for which this permit
is issued.
WARNING FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS
UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES
AND CIVIL FINES UP TO ONE HUNDRED THOUSAND ($100,000.) DOLLARS IN
ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED IN
SECTION 3706 OF THE LABOR CODE, INTEREST AND ATTORNEY'S FEES.
Printed on Recycled taper
.&- c-iix of*
Cupertino
10300 Torre Avenue
Cupertino,CA 95014
Building Division
(408)777-3228
Fax(408)777-3333
November 29, 1995
Resident
10253East Estates Drive
Cupertino, CA 95014
Subject: 10253 East Estates Drive, Permit# 27753 -100 Amp Panel
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
catling (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, y�
City of Cupertino
I
Printed o,,Rocyc/eo Paper