27500 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B ILUI\l.�K MIRE AlfPERMIT NO.
APPLICATION/PERMIT PLUbI'LNG-MBCIIANICAI. 27500
BUILDING DIVISION 1� IIUIIAINI'PRGJEC'I'1 DEN]IF'ICAII(IN'
BUILDING ADDRESS: I e. `� SANITARY NO. APPLICATIONSURRMMITTALDA'lti
D ✓ sm,� ` UNIT# LOT#
OWNERS ME: PHONE: COy[RACfOR'S LIC NO:
Q O!\]wl.\, N/C CONTROL#
.ARCI 11 rE:CI'1EN( NEER: • LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FF-F-
IJLOG ELECT PLUMB MI:CIi
PERMIT ISSUANCE. ❑ /SLI(`- MECII
OtTl
LICENSEDCONTRACfOR:SDECLARATION APPLIANCES-REMDENTIAL
pCZ JOB DESCRIPTION
I hereby charm that l am licensed underprovixions of Chrpter9(commerringwith
�00 Seeded]BW)uMinsima 3 of the Business and Professions Cede,and my license is in PANELS \,
ywF- fullforeacmdeffect.
FGW I.icritic Class Lie.# UPT0200AMPS
mad Duce Comment, 201-Ing)AMPS
1'-yZ ARCHITECTS DECLARATION SQ.FF.FLOOR AREA S/SQ.FT.
C 0°'_ I undersand my plans shall he used as public records. OVER IOW AMPS
OGF�
SIGNS ELECTRICAL
r,4 SIGNS
Licensed l'mfcvxionul
C dwu n.,I.BUILDER DF,CLARAT'ION SPECIAL CIRCUIT'/MISC.
XOaU 1 hereby affirm that I am caanin from the Convectors License law for the
t3v0<i following and Professions Any city orcounty
re TEh1P.M[?ER OR PoLF.(NST.
ht30Q which requires permit it)construct,alae,,improve.demolish,or pair nny stmcture
7n>_1 prior to its issuance,also requires the applicant for such .it'. stmedstatiamet POWER DEVICES
,t
K Q that he is licensed P....ao nuc provisions of the Can t. . lc er
d se law(Chapt
9(commeneing with S¢Tinn]BOB)nf Division Bu. c P.fessiom SWIMMING POOL ELECTRIC Cade) VALUATION
NEW RESIDENTIALELECIR
orthathcixexmnpltherefromand cbmiafar xemption.Any violation of
tZSection 703 1.5 an
S by y aant pplY=< icfor 1. hja eapplicanno
(penalty of OUTLET
S-SWITCHES-FI%'IVRES l
fiveanars
hdled doll ( ).
.
WFt] not morethan� ❑ I,m.wncrofMepmperty,orm eswith ger , nsulion. S Q FT. STORIES TYPE CONSTRUCTION
a3— will clothe work,and the.afucame in not t dedormf s (Sec. .Business
and Pmlesaions Code:The Carl. center Low s mot apply it,an owner of
property whobuditsorinnovi iherton, itwhodoessuch werkhimaelfarthrough his OCC.GROUP RES.UNITS
ownemployces,provided that such improvements arc not inoushal ,offered forsale.If,
M1nwever.tire bullthngor hnpmvemenl issold within one yearorcompleonn,the owner-
builder will have the burden of proving that he did not build or improve far purpam of
sale.). QTY. PLUMBING PERMIT FEE
❑ Lasuwnerofthe propcny.ant estluaivclyconvaning with license)convacmrs ro FLOOD ZONE APN
instruct the project(See.70,4,Business and Profenlom'Code) File Contractor's
Ucenac law does not apply to an owner ofpropeny wan builds or improves theorem and L PERMIT ISSUANCE
who contracts for such projects with.coddracl.i licensed p..a.,.,he C.ntrm'ntr's
License Law. ALTERDRAIN&VENT-WATER(FA) FEE SUMMARY
❑ 1 nm exempt under gee .B&P C for this reason BACK FLOW PROTECT.DEVICG OUTSIDER
SANITARY Y N
Owner Data DRAINS-FLOOR.ROOF.ANFA.COAD. RECEIYI'p
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ [hereby atfiren u
for l have a certifier.ofcomeno self-insure,or a certificate of FIXTURES-PER'1'RAP RECEIPI'M
PARK FEE Y N
Worken'Compensation lnaumnce or u certified copy themof(See.3800,Lab C.)which
en all employee's under this Permit ' GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIYI'a
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEMAVER 4(EA) PLANCHECK FEE
❑ Cenifiedc,,is hereby famished.
❑ CenifiM copy is tiled with the city impeaion division. GREASEWNDUSTRLWASTE-INTERCEPTOR GRADING FEE
CERTIFICATE 01;EXEMPTION FROM WORKERS, OREASHTRAP SOILS FEE
COMPENSATION INSURANCE
(This sceaift nescd not bec.mpleted iffle permit is for one hundred del)=(SIW) SEWER-SANITARY-STORM G.20pFT. ENERGY Mill.
or It
I seri fy that in the Paformaresof The work for which this permit is issued,Is hall WAT17R HEATER WNENTELECI'R
not employ any person In any manner in in m became subject .the Workers' PAID
Campereadionlawaaf CaBf.mia. Date WATER SYSTEMfFRFATTNG Date Boccie,a
0 Z Applicant
NOT'ICE'I'0 APPLICANT:If.after making this Cenificale of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
t-- y become subject o The Workers Compensation provisions of the LuMu Code,you must BUILDING FEE
> forthwith comply withatch provisions or this pend,shall be deemed revoked.
W Q CONSTR UCTION LENDING AGENCY SEISMIC PER
2 I hereby affirm that There is a construction lending agency for the performance of ELECTRIC FEE
U O the work for which This permit is issued(Sec.3097.Civ.C.) y�
Lcndcr's Name PLUMBING FEE
U" F Lender,Address Q'I'Y. MECHANICAL PERMIT FEE 6V
0 U 1 certify that 1 have read this application and sate that the alsove ndomsatiom is MECHANICAL FEE
covert. I agree to comply with all city and county ordinances andstme laws.1ming to PERMIT ISSUANCE
F-' buildingcumtruniomand hertbyamM1onve repmxnutivesofthis city t.enter uponthe CONSTRUCTION TAX
U Z shove-memionccl pmpcdy for inspection purptacs, ALTER OR ADD TO MECII.
(We)agreed,save,indemnify and kccp mandris the City of Cuacamen ugmrnt
^ liabilities,jcuu¢¢¢¢dG,menu,cosaand'"Pensee which ay in any wayacemeagahmtsaid0ty AIR HANDLING UNIT(TO 10.000 CPM)
in oat e8Bof is prnnit //5—
AIR HANDLING UNIT(OVER 10.000 CFM)
OK
Signor a Appli anVConaacmr Date EXHAUST HOOD OVIDUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IWAUI BTU) Date Receipt#
Will the applicant or future building oecupatn store or handle hazardous material HEATING UNIT(OVER 100,000 BTU) TOTAL
as deffinai by the Caliendo.Municipal Calc.Clarinet 9.12,and Ne Eicahh and Safety
Code,Section 25532(x)? VENTILATION PAN(SINGLE RESID)
❑Yea ❑No
ISSUANCE DATE
Will lheapplicntorfuarehuildingwcupuntusc uipmcntordeviaswhichemit BOILER-COMP SHP OR 100,000 BTU) ¢/r� A ' D
nodous air comam ¢m inandefined by the Bay Arca Air Quality Management BOILER-COMP(OVER 100,000 BTT))
Disain'!
1:1 Yea 11 No NEW RESIDENTIAL MECII. SQ.PI', AN 311995
1 have read the hazardous materials requirements under Chapter 6.95 of the JAN
California l health&Safety Code,Sections 25505,25533 and 25534. 1 underhand that CITY Js�
ifthe buil ding does not cmenTly have a tenure.That it is my rcspomibi Iny to notify The OF (;�rEk1)
occupant of the requirements which must be met pd.,.issuance of a Certificate of
Occupancy. 7�
Owner or authorized agent Date O'I' L: ISSUED BY:_
OFFICE J
®;
10300 Torre Avenue
(,II` ol, Cupertino, CA 95014
Cl1�JC ] L11.0 Building Division
I (408)777-3228
(408)777-3333 (fax)
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
--I have and will maintain a certificate of consent to self insure for worker's compensation,
as provided for
--I have and will maintain workers' compensation, as required by section 3700 of the
Labor Code, for the performance of the work for which this permit issued. My workers'
compensation insurance carrier and policy number are: Li-to k d '-Cllr
(this section need not be completed if the permit is for SI00.00 or less)
• --I certify that in the performance of the work for which this permit is issued, I shall not
employ any person in any manner so at to become subject to the workers' compensation
provisions of Secti n 3700 of the Labor Code, I shorthwit m ith those
provisions. DakN(::(5 Applicant.
by Section 3700 of he Labor Code for the perfo ance of t to work forI is permit
is issued.
WARNING FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS
UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES
AND CIVIL FINES UP TO ONE HUNDRED THOUSAND ($100,000.) DOLLARS IN
ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED IN
SECTION 3706 OF THE LABOR CODE, INTEREST AND ATTORNEY'S FEES.
Cupertino
10300 Torre Avenue
Cupertino,CA 95014
Building Division
(408)777-3228
Fax(408)777-3333
December 4, 1995
Resident
10954 Northseal Square
Cupertino, CA 95014
Subject: 10954 Northseal Square, Permit#27500 - Kitchen Remodel
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
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. /J
Sincerely,
City of Cupertino
Penton Un Recycled Rwat