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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OP CUPERTINO BUILDING ELECTRICAL
PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL
BUILDING PROJECT IDENT
/� Qo O 75
GIFICATION
HUIhDING ADDRI?SS:
IAT#OW
SANITARY NO.
7A1EPL1'�1,IONSUHMn-IALDAUNITM
y
S
1
s/ 1 N /
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CONIR IY)R'S A LIC NO:OL
N/C
CONTROLp
1'4EF,/: ,ICNO:
I
ADDRESS:
CONTACT:
`
I�/
10N/\
' 4/ LIA
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
EL_ IiC]' PLUMBMECIi
PERMIT ISSUANCE /
1 a_ /
LICENSED CONTRACTOR'S DFCLARATION
Ih7000) fDi Lhal umfthe wands provisions iOra sCoer 9(commencing wish
Section a and , f Division 3 of the Business and Professions Code, and my Tirana is in
full force and eD¢T.
APPLIANCES -RESIDENTIAL �-
PANELS
)OB DESCRIPTION
r�,�,{V'7
,.a —Q� �
Liana Class Lic.p
UP TO 2M AMPS
Dae Contractor
201 - 1000 AMPS
ARCHITECTS 11CLARATION
1 understand my plans shall be used as public records.
OVER 1000 AMPS
SQ. FT. FLOOR AREA
§/SQ. IT:
SIGNS ELECTRICAL
Lianxd Professiowl
SPCCIAL CIRCUIT/MI /
OWNER DIi'HON
I hereby unification I ..'BUILDER
from
Cmam rhe Cnmram,Ms License Low for the
♦ O's.
(V—(�
TEMP. METER OR POLE
following .,on. (Section 7031.5. Husiaeu vol Professions Cade: Any city or county
which requires a permit to construct, alter. improve, demolish, or repair any snsctum
prior to its issuance, also requires the applicant for such Permit to Fite a signed statement
POWE EVICFS
,he, he is licensed ......... the provisions cribs Comtmcmrs License law (Chapter
9(commencing with Section 7")of Division J afthe Businwstnd Pmfessiam Code)
amber he isexempnhemfram and the bmiafnnhe allegeA aemprinn. Avyvioletion of
Section 7031.5 by any applicant for a permit subjects the applicant in o civil penalty of
SWIMMINQPLELECIR�
9
VALUAT'ION
IF
re
not mothan five hundred dollars (§500),
[II,asownerofrhepropeny,ormy<mployces with wagnmtbeiraalecompemsaiva,
NEW R[?SID • 3 . FT.
Q
STORIW
1'YPECONSTRUCf10N
willdm the work,nnd the stmmure is not intended oruffcred hostile (Sec.J044, H®inns
and Professions Cale: The Contractor's License Law does not apply to an owner of
propeay who builds cr improves thereon, Imd who dues such work himscl f or through his
ownemployees, provided that such improvemenlsore not intendWoroffared mrsale. If,
OCC. GROUP
the building or improvement is sold within one yearofcompleion.the owner-
builder will have the burden or proving that he did not build or improve for purpose nl'sale.).❑
L
QT .�PLUM ERMIT FEE
I, as nwneroftheroperty, am exolusivelycontruming with licensed contracturem
FLOOD20NH
EUNITShowever,
construct the project (Sec. 7044, Business unit Professions Cale) The Contractor's
License l.awdteanm apply to nnownernf property who hullJs arimpmvca (hereon, unJ
PERMIT ISSUANCE 7
whence Lelxforenchprojectswhhnenmmamr(s)IicenseAputsnammlhu Cnnuueor's
License Law.
ml
AIITER-DRAIN&VEN p
( )
FEE SUMN
❑ nm exempt under Sce. , H & 1' C for this reason
BACK FLOW PROTECT. F,VICE
Owner Data
WORKMAN COMI'INSA'I'ION DECLARATION
❑ thereby affirm lhm lhuveucertifcum of cnnsenn To self-inxnrc, nru cenificmc of
Workers' Compensation lnannmce nraariOW copy ,hereof(Sn.JRIXI, Lnh CJwhich
URAINS-FLOOR, RU COND.
SANITARY Y N
RHCIiIPI'p
SCHOOLTAX Y N
RECI'IPT#
XTIJR17S-PER TRAP
PARK FlF Y N
GAS PA.SYST'1sM-I N040UTLET
covers all employee's under this permit.
Policy
RI!CIJPT#
BUILDING DIVI' NFIHI.S
an
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PIANCHECK FEE
t
❑ Certified! copy is herchy 1'umisheA.
❑ GCa1flW copy is flM wide Ne city insprninn division
GRFASFJINDUSTRL WASTE INTERCEPTOR
GRADING FEL'
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASLr TRAP
ILS FEE
SEWER - SANITARY - STORM EA. 200FT. 6
yFEE
(This section need nal he mmplemA if the pemait is 4enne hundred dollars(§I W7
or less.)
WATER HEATER WNEN ELEM.,
I realty That in the Performance of the work for which this Permit is issued, I shall
.or employ soy person in any manner so m to becomeTh
subject To e Worker'
PAID
Compensation Lawsof Celifomia. Date
Applicant
WATER SYSTEMREATTNG
O
D Receipt#
NOTICE TO APPLICANT: IL a
after making This Cenifice of Exemption, you should
become subjecto the Worker's Comp rnatumn provisions of the Labor Code, you mum
NEW RRSIDENB. TIAL PLM50. FT.
TOTAL:
T:okei. BUILDIN% �♦
forthwith mmply with such provisinnsor Nenno
is pia shall be dmm
ed v
SEISMIC Ph.
CONSTRUCTION LENDING AGENCY
I hereby affirm That Them is a cons nation lending agency for the performance of
T T st�
ELECTRIC REE
the work for which this panni, is issued (Sec. 3097, Civ. C.)
Lender's Name
Lenders Address
QTY. MEC14ANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEEmc,.
I certify that I have mad this application ani late than the above information is
l agree to comply with all city and county ordinances and sant laws relating m
PERMIT ISSUANCE
building construction, and hereby oothodu representatives ofihis city toenterupon the
above-mcmioned property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) a ee ,o save. indemnify unit keep harmless The Ciry of Cupcnino agnimt
li di,ies.'Jments,cosu end enapenxa, vhi<h meyinany way accrue. ,c JCity
AIR HANDLING UNIT (TO IO,OW CFM)
s
' con a sof egrming f i mit. \
Z
AIR HANDLING UNIT (OV ER 10,000 CFM)
EXHAUST HOOD(WJDUCD
PAID
�4►J�
5igwx of Appbcarmi ammcor ❑re
HEATING UNIT (TO 100,00) BTU)
IIA'LARDOU. IATERIAIS DISCLOSURE?
Dare Receipt #
Will the applicant or future building occupant store or handle hneardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Surety
HEATING UNIT (OVER IW,(gO BTU)
T'O AL:
Coda, Section 25532(x)'!
❑ Yea ❑ No
#
VENTILATION FAN (SING RE9ID)
Will appliamnrfumrcbuilding occupum useeyuipmemnr Jevic,,a whichemit
'..wmbas air cnnt'ammicas ns defined by ,he Bay Arca Air Quality Management
District?
❑Yes ❑ No
SU A E E
BOILER. COMP(3HPOR I(p,000 BTO)
BOILER- COMP (OVER IOO,OtHI BTU)
NEW RESIDENTIAL MECIL SQ, FT.
I have real The hm,ardnua mpaermis rcnptiremeals wader Chapter 695 of The
California Health & Softly Cale, Sections 2.1505, 255331md 25.534. l understand (hot
If the building duos not currently hove a mita,, than it ix my.......slbi it m nal ify Tho
occupant of the reqs acracros which must Iso mel prier to Lssuouee of u Cerli Galla of
Ooaupancy.
ISSUED BY:
Owner ar aulhnri.1 agent Dae
TOA
OFFICE
of
10300 Torre Avenue
Cupertino, CA 95014
cuperthio
Building Division
(408)777-3228
(408)777-3333 (fax)
February 23, 1996
Robert Jardine
10500 Mira Vista Avenue
Cupertino, CA 95014
Re: Permit #28075
DearRobert Jardine:
Our records show that the referenced permit has not been finaled by a City building
-. inspector. A permit is 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, Ci;pertino, 95014, Attn: 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 date of receipt of this letter. If we do not hear from
you, the City of Cupertino Building Department will have no recourse but to resolve your
permit as expired and discard the records.
Thank you for your assistance.
CITY OF CUPERTINO
•
Pnnteo on Pecvcie7 Pape.,