25105APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -
CITY OF CUPERTINO APPLICATION/PERMIT
BUILDING DIVISION I—
LIC&35ED CONTRACTOR'S DECLARAT ION
nay Iherebyaffirm thatlum licensod undcrprovisionsofCTapter9(cotrunencing with
u100 Section 2000) of Division 3 ofthe Business and Professions Code, and my license isin
F�1, ou farm full and effect.
QZLicense Class Lic.#
ccoQ Date Contractor
1-,z ARCHITECT'S DECLARATION
z O y—
OZ—O 1 mider mad my plarn shall be used a public records.
g¢, -7d Licensed professional
1K�C6 OWNER -BUILDER DECLARATION
OW, 1 hereby affirm that I am exempt from the Comm cam's License Law for Ne
W 3la.ti follnwingreason,(Section ]031.5, Business and Professions Code: Any cityo. county
F- O which requires a permit to construct alter, improve, demolish, or repdr any worm.
prior to its issuance, also requires the applicant for such permit o file a signed statement
that he is lacnnd pursuant to the provisions; of the Crommud'a Limmc law (Chapter
X.9(usnarcucing with Section 9000) of Division 3 of Business and Ptofbssimce Code)
y)_eo onhat he is exempt therefrom and the basis for Ne alleged exemption. Any violation of
l.-_ Q Section 7031.5 by any spot cant for a permit subjects the applicant to a civil penalty of
n are than five hundred dollars (S50%
W� crmfthepro,,Iy,.r my employees wall..i ,aa theirsole compensation.
W3— disks work.and the structure is not intended or offered for sale (Sm.]054. Business
and Pndessionx Cdei The Conrai License Law does not apply to an ownersoqf
property who builds or improves thereon, and who dues such work himselfor through M3
owo employees, provided that such improvements are not Intended or offend for sale. If.
however. the building or improvement is sold within one year of completion, the owner-
builderwill have the burden ufpnwid, that he did not build or improve for putpou of
sade.).
❑ n
I,as rofthepropm eny.aexclusivelyconimctingwiNlicmwdeonractomto
concoct the project (Sec. 7044, Business and Professions Code:) the Crimson, ,s
Licenu Law docs not apply to an owner ofp aiwo, who builds or improvestherms, and
who contracts for such projects with acorsnt m
nractorts) licensed puuathe Convectors
Limme Law.
❑ I am exempt under Sec. . B & P C for this reason
Owner Due
WORKMAN COMPENSATION DECLARATION
❑ I hembyaffirns that l have acenifcate ofcomenttoself-insure,ora certificate of
Workers' Compensation Insurance or a cenificd copy thereof (Sm. 3800, Lab C.) which
—61, covers all employee's under this permit.
Policy If
Company
❑ CcnlfcicopylsheRbyfumished.
❑ Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
phis.section need not he completed if the permit is bounce hundreddollsrs ($100)
or less)
1 certify that in the peRorsomme of the work far which this famous issued, I shall
nm employ any person in any trance, so as m become subject m the Workers
Compensation Lawsof Califomia. Date
Applicant
NOTICI: TO APPLICANT: IG after making this Cee ficate rf Excmptioe, you should
become subject to the Workels Compersution provisions of the Labor Codc, you must
forhwlth comply with such provisions or this Permit shall bo deemed rooked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm thauhem is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 309?. Civ. C.)
Lenders Name
Lenders Address
1 certify that I have read this application and state that the above information is
correct. I ague to comply with all city and county ordinances and state laws rehting to
building construction, and hereby authorim representatives of this city to enter upon the
above-mentioned property for inspection purpoxs.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
in consequence
HAYARDOUS MATGKTAIS DISCLOSURE
Will the applicant or future building occupant stop or handle hazardous material
as de( ced by the Cupcnino Municipal Code, Chapter 9.12, and the Health and Safety
Codc. Section 255320)?
❑ Yes ❑ No
Will the upplicaet or future building occupant use equipment or devices which emit
�mrlous air contaminants as defined by the Bay Area Air Quality Management
)la cicontaminants
Cl Yes ❑ Na
1 have read the hazardous materials requirements under Chap¢, 6.95 of the
California Hcalth & Safety Code. Sections 25505, 25533 and 25534. 1 understand that
if the building does not currently have a tenant that it is my responsibility to notify the
occupant of the requirements which must bo met prior to issuance of is Certificate of
fhmpancy.
Owner or authorized agent Dam
PLUMBING - MECHANICAL.
INII'N LOT#
'ONTRACfOR'S NAME:
/
)TY. ELECTRIC PERMIT
PERMIT ISSUANCE
. PPLIANCES - RESIDENTIAL
PANELS
UP TO 200 AMPS
FEE
201 - 1000 AMPS
OVER IM AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUOyMISC,1
TEMP. METER OR POLE M
POWER DEVI IS v
SWIMMING
O -SWITCH
NGWYRFS1% .E SQ. FT.
i
110
s
TOTAL:
PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER - DRAIN & VENT- WATER (EA)
BACK FLOW PROTECT. DEVICE
FIXI'OR ES - PER TRAP
GAS - EA. SYSTEM -I INC. 4 OUTLETS
GAS - EA. SYSTEM -OVER 4 (EA)
GREASFANDUSTRL WASTE INTERCEPTOR
GREASE TRAP
SEWER - SANITARY - STORM EA. 2001T.
WATER HEATER W/VI NT/ELECfR
WATER SYSTEM/IRE VHNG
NEW RESIDENTIAL PLMB. SQ, FT.
Ilmralt
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH,
AIR HANDLING UNIT (TO 10.000 CFM)
AIR HANDLING UNIT' (OVER 10,M) CFM)
EXHAUSTHOOD (WMUCO
I MATING UNI' 1'('10100,000 BTU)
HEATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RFSID)
BOILER - COMP (311P OR 100,000 BTU)
BOILER - COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECII. SQ. Ff.
TOTAL.:
FEE
—sol ",.. 25105
SANITARY NO. APPLICATION SUBMITTAL DATE
4
CONTROL#
BUILDING PERMIT INFO
OLDG
EIEC-IY PLUMB MF
CH
❑l
�I�OlB DDIIP
Ir:SCRIN ❑
G-dW_4 "
SQ. FT. FLUOR AREA S/SQ. Fr. .
�T? 201(8
�VsAraL�U(1A�T#
ST CJLJL�IaO1�N
LTYPE CONSfHUCI'ION
r OCC GROUP EAPN
S
u
FLOOD ZONE
FEE SUMMARY
VI'SID: EES
SANITARY Y N
RECEIPT a
SCHOOL'1'AX Y N
RECEIPT
PARK FEE a,
fa Y N
CEI T #
11 DIVISION FEES
PLANCHECK
GRAFDINCfFdr1�1
SOLI. EE
ENERGY IZE
PAID
Date Receipt#
TOTAL:
BUILDING FEE
SEISMIC FEE
ELECTRIC FFE
PLUMBING FEE
MECHANICAL WTI
CONSIRUC IONTAX
PAID
Date
PAID
of,
10300 Torre Avenue
Cupertino, CA 95014
Cupertino Building Division
(408)777-3228
(408) 777-3333 (fax)
0
April 23, 1996
Resident
10413 Meadow Place
Cupertino, CA 95014
Re: Expired permit (copy attached)
Dear Resident:
According to our records, the referenced permit has not 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 (408) 777-
3228, so we may arrange to extend your permit and schedule a final inspection.
The City of Cupertino requires a response within ten (10) working days from the date of
receipt of this letter. If we do not hear from you within this time, the building department
will have no other recourse but to resolve your permit as expired and discard the records.
Thank you for your cooperation,
Building Department Staff, City of Cupertino,
Prinletl nn Reayoled Paper