25223 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI'T'Y OF CUPERTINOButl�sllvtrEr.Rt rRrcA, PERMITNo,
APPLICATION/PERMIT PLUMBING-MECHANICAL 25223
BUILDING DIVISION BUILDING PROJECI'IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICVHONSUBMGTAL DATE
2 Z / / L L I` T/� UNIT# L07:a �16�
-�
OWNERS Ngfv1E: PHONE: CONTRACTOR'S NAME: LIC NO:
el 1r/II — — &M9YTiONE �/ y/ "7� N/c corvrRo a
*ARCHITECUENGINEER: LIC NO: ADDRESS:
14"116-6-,0,_ AA' AVE-, ('AMj0S zF _
PCUNIA�: PHONE:
QTY. ELECTRIC PERMIT FEF, BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ID ❑ � �.Ir
SED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION ISL
Matz am licensed under provisionsofChaper9mommencing with
yWWOOWUndefSof the Business and Professions Code,,and my license is in PANELS r
,f- full forest Lienee Jeffect.
LQ,Lm Data
' C-ZO Idle.# YYS/ L Z IIP T0200AMPS
slay Oatc �� ' y Contractor In NnA9se.e/fo .�(/Yfi 201-1000 AMPS
ZF&
on DECLARATION OVER 1000 AMPS SQ.FI'.FLOOR AR Ii $/SQ.Fr.
O'Z^M I mcconindmy pImr,hall be ucd as public records.
W SIGNS ELECTRICAL
QQ Licensed Proms mmol
aWd'6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KOiU I hereby affirm that I am exempt from the Contractors License Law for the
W 3 a y¢ fallowing mason.(Some.7031.5,Business and Professions Code:Any city or county HMP.METER OR POLE INST.
f-LL' J which requires a Permit to construct,alter,improve,demolish.or repair any structure
a� pdortoill issmerea.alsurequlrestht
sit'licanfors.chpcmdlmfile.signedaUrcment POWER DEVICES
m C OOm that he is IicnacJ punuanno the provisions of the Contm um's License Law(Chapter SWIMMING POOL ELECTRIC
aKOLL Site racndng with Section 7")of Division 3of,ha Business and Proressiom Code) VALUATION
W_rn or that he is exempt therefrom and the basisfonbe alleged exemption.Any vlola0on of OUTLETS-SWRCHFS-Fl%TURFS
FlaSection 7031.5 by any applicant fora psocan ubjeandr,applicanuua civil Penalty of
not mom than five hundred dollars($50(B.
Q NEW RESIDENTIALELECfR _SQ.Fr. STORIES TYPE CONSTRUCTION
22 ❑ I,osnwrk.an hepmpeny,a is not
forslhe(Sce.compensation.
L will dolbcwons Could he CorelsnotinLnense Lawredlbrst apply 7044,Business
send I'rofcasions Crmdc T3mc Convomars License how docs not apply to an owner of
propcny whobuilds aimproves thereon,and who doe,such work himselforthroughhis
own employees,lding or i porscb ant iss sold
wit im nut intended mattered forsale. r-
OCC.GROUP RES.UNITS
however.ilderwthe buildingorimpmvememnissoldwithinone yea or impao efor thrower- TOTAL:
builJer will have the burden of proving that he did not build or improve for purpose of '
sale.). a QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ I,aanvfnerofthepmpenY,amexclusivdreontractingwslhlicens contr canto
construct the p-i(Sec.7(u4.Business and Posenions Code:)The Cunuan0r'a PERMIT ISSUANCE
License Law docs nor apply to an owner o f property who builds m improves theremm,and
whoconmesfor such projects with acumoselor(s)licensed pursuantto the Convectors
License LowALTER-0 (E
DRAIN A) I•tiE SUMMARY
.
❑ 1 am exempt under Sec. ,B&P C for Nis remain OUTSIDE FEES
BACK FLOW PROTECT.DEVICE SANITARY Y N
Owner Dam RECEIP #
DRAINS-FLOOR,ROOT',AREA,
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
® ❑Workers'
Comaffpensation
that lhave acor a certified
cinsent copy themcf(ee.3.or Lab C.)e m ofwhich FIXTURES-PER TRAP R[CEIPI'#
J Workeri Campensstion lnsurananrucertificd copy tbercaf(Sw.3800,Iab C.)which PARK FEE Y N
coven dlemployee's undcnhi L GAS-EA.SYSTEM.I INC.4 OUTLETS HDIVISION
Policy
# BUILDING DIVISION FEES
Com y �(Ilatrttf6J d'TILrV A 4— GAS-EA.SYSTEM-OVER 4 EA) PLANCHECK HE
3"Cemfied copy is hereby furnished.
11 Certified copy is filed with the city inspection division. GREASEIINDUSTRL WASTE RCEPfOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' ORFASETRAP SOILS FEE
COMPENSATION INSURANCE
('ITiesedion need not be completed ifthe permit is Income hundred dollars($UK) SEWER-SANI'T'ARY-S'1'ORM F.A.200FT. ENERGY FEE
or le".)
I cmify that in the performance,ofthe work for which this permit is issued.I shall WATER I[EATER W/VENTI L'Cf
m employ any person in any manner so as to become subject to the Workers' PAID
Cnmpcnvtima Lawsof Caliromia. Data WATER SYSIEMlfRFA'TIN Dae Receipt
Q Z Applicant
Z NOTICE TO APPLICANT:IL after making this Certificam of Exemption,you should NEW RFSIDENTI ,MB. S .FT. TOTAL:
f" ry bcconexubjec ser,the Workers Compensation provisions ofthe Tabor Code.You must
> fonhwith<omply with such provisions or this permit,bal]be dcemed revoked. is. � BUILDING HE
Q CONSTRUCTION LENDING AGENCY i SEISMIC FEE
.7 Z I thereby arfim that them is a construction lending agency for performance of \ TOTAL: ELECTRIC FEE O the work for which this permit is issued(Sec.31097,Civ.CJ
L3+ I<ndcrs Name PLUMBING HE
handler's AJdmss Q MECHANICAL PERMIT FRE
W 1 eerily that 1 have read this application and state that the above information is MECHANICAL ITE
�" coned.l agree to comply with all city and county ordinances and sate laws relating to PERMIT ISSUANCE
huilding commieion,and hereby authon.mpirsenativu of this..tyro rnt upon the
(� CONSTRUCTION TA%
Z above.mentioned Pontiac.,for inspection purposes. A TER OR ADD TO MECH.
(We)agree le.cove,indemnify and kap forand ss the Ory of Cupertino eBain't
Iiobilitin,jud8mena,crosa and expenes which may in any way accrue against said City AIR ANDLINGUNIT(IrOl0A00 M)
in curseYYgKKK fthe eantin o t.
AIR NDLING UNIT(OV e0l
lI00 CFM)
Sig nature of A,licanr/Commd r Date E%HA I'HrRJD(W PAID
HAZARDOUS MATERIALS DISCLOSURE HEATIN O 110,003 BTU) Date Receipt#
Wllllhe applicant or future huffing necupma store nr hmadle haaardous material HEATING UNIT(OVER 100,000 BTU) TOTAL:
as Acrinol by the Cupertino Municipal Crate,Chapter 9.12,road the Health and Safety
Calc,Section 25532(a)7sa VEM'ILAT'ION FAN(SINGLI3 RPSID) �'
Cl Yet, umgNu ISSUANCEDAT
Will thea Iicamorfmure buildin tusse tordevicas whichemit BOILER-COMP(3HP OR 103,000 BTU)
pP 8by then Sea Air
hnrardous air contaminants u defined by the Bay Area Air Quality Management BOILER-COMP(OVF.R 100,000 BTU)
DixWn7
❑Yes ITN. NEW RESIDENTIAL MECH. SQ.FT.
1 hove mad the hazardous materials requlmments under Chapter 6.95 of the D
California Health&Safety Cede,Sections 25505.25533 and 25534.I understand that
Bmeaepmaaiminthg d« OCT4
1
Occuprt 1J
/Q^2l 9 a
Owner 4,multuaroxedagent Date I SI]J��VI
CitV of
Cupertino
10300 Torre Avenue
Cupertino,CA 95014
Building Division
(408)777-3228
Fax(408)777-3333
September 20, 1995
C. Agrawal
22191 Me Clellan Road
Cupertino, CA 95014 `
Subject:22191 Me Clellan Road, Permit# 25223
• 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
• I r� , r. .,nfl.�,l,�t
Printed on Recycled Piper
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