27470 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF C[JPERTINO BUILD;NG
-F.LF.CTRICAL PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMewG-MECHANICAL 0
BUILDING PROJECT IDENTIFICATION
BDI GAppRF.SS: .. I SANITARY NO. APPLICATION SUBMITTAL DATE
1_7 4?664 .UNIT# LOT (,—�/�I
OW E NAM' PHONE: C TRACfOR'$NA LIC /� / N/C CONTROL#
RCHI CT/ENGINEFB: LIC NO: S& Lll r� ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMV MECH
PERMIT ISSUANCE Pee
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL. JOB DESCRIPTION
ay Thereby affirm that am licenseduoderprovlslonsirm p[u9(wmmeaense is.
�O Secriona000)af Di aa3 offie Business an Pr fcgsians Qgde,and my license is in PANELS
UG fitillfirreasLcnseClnd /(/9//
6z u] License Class ic.# UP T0200 AMPS
n, a, Dale xContme[o ''1I1' 201-1000 AMPS
Z FO N Z ARCHITECTS DECLARA I W SQ.FT.FLOOR AREA $/SQ.ET.
OVER 10(X1 AMPS
O Z-, I understand my plans shall be used as public records.
gym[
tq SIGNS ELECTRICAL
Ucoosed Professional -
, Ot I am a UILDER DECLARATION Com TION SPECIAL CIRCUIT/MISC.
ipp'��d,00< I hereby nationmason.(Scene.
that I am exempt from the Contractors License Lew for the
1+]3Wm followingreason.(Section 0031.5,Business endue,de Profession.Lane:Anycity orcounty TEMP.METER OR POLE!NST.
f5�; prior
t requires apermitra construe[,alma Improve,h Permit to
or repair anytatemero
'hat he is licensed
ensedpalso requires the visio s oforsochpenniuoLice signed statement POWER DEVICES
- p that he is licensed pursuant m the provisions of the ntmaor's License Lew(Chapter
myo�L 9(commencing with Section 7000)of Division 3 crib uainessand Professions Code) SWIMMING POOL ELECTRIC' VALUATION
iVF�.�m orthat he is exempt therefromanl the basis foJthea d exemption.Any violation of OUTLETS-SWITCHES-FIXTURE$
C�QSection 703 LS by any applicant fora pe�mi . pelican[bacivil penalty of
KA not more than Eve hundred dollars($5(q). /�.� NEW RESIDENTIAL ELECTR S FT.
Fm ❑ I,asowneraftheprnperty.ormyemplay wage e�JlpCtts/lion, Q' STORIES TYPE CONSTRUCTION
will codes woh,indma,min tma is not in offered( I }04M1, mess
antl Professions Code:The Con[rac i n Lew does map to an owner of
property who builds oritopro s@e on, d hoJ�°°� ucfw khimselfarthroughhis OCC.GROUP RES.UNITS
employees,providedthata c rov intendedoroffersdaveale.If,
however,mebuildingori is sold yearofcompletlon,theowner- TOTAL:
builder will have the burden ro P g that he Sdi not build or improve for purpose of
sale.).
❑ La menscrofilml )party, clusivelyconhacting with licensed contrectorsto QTY' PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.2044,Business and Professions Coded The Contractor's ' PERMIT ISSUANCE
License Lawdoestotapply to an ownerof propertywhol uiids or improves thereon,and
who contracts for such projects with sconvector(s)licensed pursuantto the Communes ALTER EA
License Law. ( ) FEESUMMARY
❑ 1 ton exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE T
SANITARY Y N
Owner Dam DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX V N
❑ Thereby affirm thetlheve acertificnm of❑mount mkelf-insure,mecerafictimid RECEIPT#
FlXTURES-PER TRAP
Workers Compensation lnsurenceorecertified copy thereof(Sec.3800,Lab CJ which PARK FEE Y N_,.
mersall t mi - - RECEIPF#
GAS-F.A.SYSTEM-1 INCA OUTLETS
Palicyq BUILDING DIVISION FEES
Can parry i rrr GAS-M.SYSTEM-OVER 4(EA) PLANCHECK FEE
11Cin, t copy Is li r furnished-
❑ Certified copy is with the city inspection division. GREASFIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need sot be❑ample¢d iftheperrad is for one hundreddollers($100) SEWER-SANITARY-STORM EA.20017. ENERGY FEE
or less)
I certify that in the performance office work for which this permit is issued,l shall TER HFA NENT/ELECTR
not employ any Person in any manner so.to income subject to the Workers' PAID
Compensation Lawsof Califomla. Date WATER SYSTENUTREATING Date Receipt#
z Applicant
z NOTICE TO APPLICANT:If,afmr making[bis Cenifcata of Exemption,ymirbould NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
,r V) become subject to the Workers Compensation provisions of the Labor Code,you must
forthwith comply witleach provisions or this permit shall be deemed revoked. BUILDING FEE
W I~ CJNSTRUCTION LENDING AGENCY SEISMIC FEE
Z
r✓C-I 1 hereby affirm and them is a construction lending agency for the performance of TOTAL: ELECTRIC ME
O the work for which this permit Is issued(Sec.3M7,Civ.C.)
Lenders Name
CL E~ PLUMBING FEE
Lender's Address QTY. MECHANICAL PERMIT FEE
IU I.I agree
that I have read this city
and
and seem that ad above information is
�"' corset.Iagreemcomply with all city and county ordinances and state laws relatingm PERMIT ISSUANCE MECHANICAL FEE
Co) building construction,and hereby aumoriurepresentatives ofmiscity to treatment the CONSTRUCTIONTAX
U z above-mentioned property for inspection purposes, ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,jul noors,costs add expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
in wneqft�he gmmgt AIR HANDLING UNIT(OVER
10,000 CM)
WaUA ¢anV Data EXHAUST
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam Receipt#
Will the applicant or future building cocupant store or handle hazardous material HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health end Safety
Code,Section 25532(x)7
❑Yes ❑No VENTILATION PAN(SINGLE RESID)
ISSUANCE ATE
Will theapplicanmrfummbuildingoccupantuuegripmenmrdeviceewhich emit BOILER-COMP(3HP OR 100,000 BTU)D' pp
tazamous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMEtOVER 100,000 N BTU) P ID
'
smic@
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have read the hazardoms materials requirements under Chapter 6.95 of the FEB 16 19
Califomia Health&Safety Cade,Section.25505,25533 and 25534. I understand mat
if the building does not urrently have a tenant,that it is my responsibility to notify the
occupant of the requirements which must be met prior to issuance of a Certificate of V I I Y /71' V of Lt s 1
Occupancy.
Owner or authorized agent Data TOTAL: ISSUED BY:
OFFICE
I
®r .
„f,
Cupertino
10300 Torre Avenue
Cupertino,CA 95014
Building Division
(408)777-3228
Fax(408)777-3333
November 29, 1995
Resident
19983 Lindenbrook Lane
Cupertino, CA 95014
Subject: 19983 Lindenbrook Lane, Permit#27470 - 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.
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
flnal inspection.
4 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 V
i
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