27133 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL'POINT PEN ONLY
CITY OF CUPERTINOmon.........P,rRIUAI. PERMIT NO.
BUILDING DIVISION
APPLICATION/PERMIT PLUMBING.MECHANICAL
PROJECT ' 'I'INICATION 27 'I1 33
ISU11.UiNG
BUILDING ADDRESS: �//I���/� SANITARY NO, APPLICATION SU`BMI'TII'AgL DATE
2�- vW UN 1p I
LOTa
OW 'iS N�! P°' PHONE: COMIRACTOR'S NAe • LIC NO: J L
NIC COMIROLp
10-RCIHTF,CI'R3NGINEER: LIC NO: ADDRESS: ❑
CON'1'ACf: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE -TY 11
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB SCgIMID
py,Z Ihereby affirm that l sen licensedunderpowisions of Chapmr9(commencing with �/� •r\ev'1!1
ju 00 Section]BW)of Division 3 of the Business and Professions Cade,and my license is in PANELS 1 � ` ,(�/Y ``•1�
ful l force and effect. l
FtW Liccnac Clens Li # UPT02W AMPS
u
mQy Date Contractor 201-TWO AMPS
ARCHITECTS TS DECLARATION OVER 1000AMP5 SQ.IT.FLOOR AREA $JSQ.FT.
GOv,FyI understand my plans shall be used as public records.
OG—G SIGNS ELECTRICAL
QN
Ywj Licensee Professional
Ll,w< OWNER BUILD ER DECLARATION SPECIAL CIRCUIT/MISC.
iaC Oa V 1 hereby affirm m theeConvethat 1 aexempt from ctors License law for the
W3ay following reaanu.(Sermon'/It3 1.5.Rosiness and Professions Cade:Any city or county TEMP.METER OR PoLE INST.
which
myuiresupermit ro consWa.'do",improvq Jemolisn,or repair any aWcwrc
KQ� prion.its ismance,also rectums theapplicant fmstch permitmfilev signed statement POWER DEVICES
W K Q p tum he is licensed pursuant m the provisions of Ne Convectors License Law fChapmr SWIMMING POOL ELECTRIC
a o 9(cmmomcirg with Section 7")of Division 3 ofthe Business and Professions Code) VALUATIQkICrc
but he is exet,pitherenrom and rite basis for the alleged exemption.Any viclation01' OUTLETS-SWITCHES-FIXTURES `� 11As-0 UUP
�yrQ, Section➢031.5byanyapPlicumfnrapcnnitsubjectstheapplicannuecivilpeneltyof
Sxp not more diva five hundred dollars($50)). NEWREUDENTIALELECIR _SQ.FT. STORIES TYPECONSTRUCTION
yFo ❑do the
work.
anhepmpcny.ormyempindedorthwegesasaleirwle c0m,Busmen,
y3� will Jolhework.enda he Concturetractor's
Licenseawdoeffiered sot apply
Business
and Pmfcssiom Cinle:The Cnntrador s License Lew Jwa not apply to an owner of
property who builds m improves thereon,and who does such work himself or du,ugu his
OCC.GROUP RES.UNITS
cmployus,pmvidedthatsuchimpmvcmcnmmnmintendWwoffer forWe.IL
hove es,the building or lmprovemem issold withln,neyear,(completion,the owner-
IF der ill havethe burdenof proving tent he did oar bund s improve for Purpose of
f the pmpenm y.aexclusively contracting with licensed cono-ectors to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
mstrva the prorace
(sen.7064.Business and Professions Cer l The Conv¢tor's
nsc 1.aw Jnes not apply manownernfpopeny who builds orimproves thereon.and PERMIT ISSUANCE
ibsnmvacts fnrsach projects with aaommcmr(s)licenttd pursuant it) Contractor's se Law.
License
ALTER-DRAIN&VENT-WATER(GA) FEE SUMMARY
❑ l am exempt under sec. ,B&P C for this mason O SIDE FEE
BACK FLOW PROTECT.DEVICE SANITARY Y N
Owner Date DRAINS-PI.00R,RODE,ARGA,CONU. RECEIPTp
WORKMAN COMPENSATION DECLARATION SCIIOOLTAX YN
❑ Ihereby affirm that iharcecenificvm of mnsem to xlf-insure,ore cenificam of FlXTURES PER TRAP RT:CF.IpT#
Worker,Compensation Insurance or ac<nified copy thereof(Sce.3800.Lab C.)which PARK FEE Y N
covers all cmployc2.c under to,pemmit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RF. p
Policy# BUILDING DIVISIVISION FEES
Company GAS-EA.SYSTEM OVER 4l EA) PLANCIIECK FEE h LAS
❑ Certified copy is hereby fumishdl.
❑ Cenified copy is filed with the city impeemor division. GREASWINDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICA'E OF EXEMPTION FROM WORKERS' GREASP,TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not becompleted ifthe Permit is Toros hindrdd011an(SIM) SEWER-SANITARY-STORM EA.2WFT. ENERGY HE
or less.) ,
I certify that the'Nafornance ofthe work for which this permit is issued,]shall WATER HEATER W/VENT/ELECfR
not employ any person in my mariner so as to become subject to the Worker, PAID
Compensution Lawsof Califomia. Date WATER SYSTEMTREATING Dae Recelpr#
zz Applicant NEW RESIDENTIAL PLMB. SQ.Ff. TOTAL:
O NOT ICE TO APPLICANT:IL after making this Ceni fears of Exemption,you should
P
lecome subject to the Workers Compensation Provisions of the labor Code,you must BUILDING FEE
P 7 forthwith comply with such promotions or this permit shall be deemed revoked. I �•
W F CONSTRUCTION LENDING AGENCY SEISMIC ITE
z 1 hereby affirm that there is a construction lending ugency for the performance of O
U O the work for which this permit is i...ed(Sec.3097.Civ.C.) OT 1 ELECTRIC ifi
Lender's Name PLUMB/46 FEE
u' F Lender's Address QTY. MECHANICAL PERMIT FEE
U 1 e mil,that I have read this apdictnin.and state that the vbove information is ME ANICAL FEE
W Boren.l agree to comply with all city and county ordinances and state laws mlating to PERMIT ISSUANCE
F" 0. builddgeonstraction,and hereby authorize represenmtivesafthis city to enter upon the ONSTRUCTION TAX
U z above-memimmed propeny for inspection purposes. ALTER OR ADD 10 MECH.
We)agree to rove 'ademnify and keep harmless the City of Cupertino egamst
fish'line"jm1noco oat "deipedoes may in any way ac,me.tainst said City AIR HANDLING UNIT(TO 10,000 CFM)
q -ace the ting of this
�O-as AIR HANDLING UNIT GVM 10.W0CF
S mamreo pplicam/Co actor Dam E%HAUST HOOD(W/DUCU
HA' FOCUS MATERIALS DISCLOSURE HEATING UNIT(TO IW, '1'U) D e opt#
W,
the applicant or future building occupant store or handle hazardous material HEATING UNIT(OV. IME W BTU) / TOTAL:
as
efned by the Cupertino Municipal Cde,Chapter Y.12,and the Health and Safety
Co de,Section 25532(x)9 VENTILA9'10AN(SIN GLG RI?SID)
❑Yes ❑No
BOILER/OMP0X,
(3HP OR 1000 BTU) 'SUANCF,DATE
Will the applicant or fnumebuildingacupanmseeedipment ordevices which emit gg�� /k
A
hazmdous air comamas defined defined by the Bay Arta Air Quality Management BOX .R-COMP(OVER I W0M, BTIH sr D
�Ul.tlrlCl^
❑Yes ❑No NEW RESIDENTIAL.MECH. SQ.FT.
1 have read the hazard..,mumrids rcqummants under Chapter 6.95 of the OCT 251994
Cal forms IIcahn&Safety Coda,Sections 25505,25533 and 25534. 1 and...tend than
it the building does nm currently have a tenant,that itis on,resp oli ciliry to notily the /sl I I,
occupant of the re piremcnts which mud be met prior m issuance of a Certificate of V VJ- V U
Occupancy.
Owner or uulhnrized agent Dale TOTAL: ISSUED BY
OFFICE
t
;® t
, v
- ' City of
Cupertino
10300 Torte Avenue
Cupertino,CA 95014
Building Division
(408)777-3228
Fax(408)777-3333
September 20, 1995
Southland
21490 Me Clellan Road
Cupertino, CA 95014
Subject:21490 Mc Clellan Road, Permit#27133
• Dear Sirs,
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
•
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