27453 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO
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APPLICATIO /PERMJIT PLUMBING.MECHANICAL
BUILDING DIVISION INILUING PROJECTIDENTIFICATIUN 3
BUILDING ADDRESS:O {1► 1� c(n� SANI'I'ARYNO. APPLICATION SUBMITTAL GATT
'O 0Ww 51 UNIT'# a LOT If - g
OWRS NAME: PHONE CONT CTOR'S NAME: LIC NO:
ph NrA 25$- 792 G�,L La...sk- N/C CONTROL
ARCHITIiC'I'/ENGINEER: LIC NO: ADDRESS:
4495 0 1(10.4 00. S-
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLU H MECII
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
pyr Ihereby oflimt that l am licensedunderpmvisions ofainer9(commaaemgwith
O Section mk of Division 3 mom Business and Professions Code,and my license is in PANELS
full force and effect. UP T02W AMPS
Q- License Cluca Lia.tl a—"ii,. I
tFisQd
Data Contractor 201-IWO AMPS
F'Oi.Z ARCHITECTS DECLARATION
I'.
ZCIL OVER IOW AMPS SQ.FT.FLOOR ARG $/SQ.I
O Z—O I understand my plans shall be used as public records.
F y F W SIGNS ELECTRICAL
Licensed Profusional
CCQ that
I am-exempt iRmDECLARATION SPECIAL CIRCUIT/MISC.
0.0yU I hereby Anion.(Sc thm I am exempt from the Conions Cs License Lew for the
tr1'%a ti which followingreason.(Section construct,
Business and ase,deriom Cade:Any an stcounty TEMP.METER OR PoLE INST.
which requires a pemdt to rnnstmm,elfin improve,demolisM1,or rtpay.ny so-uctme
to_1 prior its issuance,also requires the applicant Permit file a signed statement POWER DEVICES
rt
y�j(1 pa that he is licensed pursuant tame provisions of the Contractor's License Law(Chapter
a 'oLL 9(i,ommcncing with Section 700o)of Division 3 ofine Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
Amy mind he is cxempftherelmm and the basis forthealleged exemption.Any violation of
F_ZQ Section 1031.5 by any applicant for a permit subjeets the applicant to a civil pe rely of OUTLETS-SWITCHES-FIXTURES
not mum than five hundred dollars($500). NEW RESIDENTIAL ELECTR _SQ.FT.
ce, ❑ 1,asownerofthepropcny.ormyemploymswithwagesmtheirmlecompensat., STORIES TYPIiCONSTRUCTION
y3?o willdo the work,and the structure isomimmmdedoraffered for sale(Sec.0044,Business
and Professions Cade:The Contractor's License I.uw does not apply to an owner of
prcpeny whobulldsor improvesimmon,and whodoes such work himselforthroughhis
employees.provided that such improvements arenmintended motored forsale.IL OCC.GROUP RLS.UNITS
however,the buildingor improvement is said withinoneyearofeampletion,themomr- TOTAL:
builder will have the burden of proving for he did not build or improve for puryme of
talc.).
❑ Lu.ownm onhe propmty,amexdusivdy wtmramingwith limmed mntracwram QTY, PLUMBING PERMIT Mir, FLOOD ZONE APN
construct the project(Seo.70LI,Business and Professions Code:)no Contractor's
License L.awdoesomripplytoan.wnerofpmpeny who baildsm impmvesthemon,and PERMIT ISSUANCE
whorommem forsuch projects with.contractor(')licensed pursuant tothe Contractors ALTER-DRAIN&VENT�WATF,R
License Law. (EAG FEE SUMMARY
❑ 1 am exempt under Site ,R&P C for this reason BACK FLAW PROTECT.DEVICE OUT SANITARY Y DEDE E
N
Owner Dam RECEIPT#
DRAINS-FLOOR,ROOF,ARG,COND.
WORKMAN COMPGNSA'fION DECLARATIONSCIIOOI.TAX YN
❑Workers
Co pen that)hrance or aBam od copy
.3800,Lab C.)which
FIXTURES PER TRAP RECHIPI'p
Workers Cmployee,mark,this Insurance or ified copy Nertof(Sm.3800,Lab C.)which PARK FEE Y N
rs all employee's under this permit. GAS-G.SYSTEM-1 INC.4 OUTLETS RF. p
Policy p BUILDING DIVISION ITiCS
Company GAS-EA.SYSTEM-OVER 4(G) PGNCHECK FEE
❑ Cetified cop/is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASEANDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKER ' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This sonar.used not be cnmple the permit is for one hu rcddollars(000) SEWER-SANITARY-STORM P.A.2WFT. ENERGY ITE
or less.)
I mind,that in the perform�m r, rk for what t t is issued.I shall WATER HEATER W/VENT/ELECIR
not employ my person in anY u t s bj t to the Workers' PAID
Compensation Laws of California. e a WATER SYSTEM(IRGTING Date Receipt#
O z Applicant
Z � N01'ICE'fOAP LIC term this Ce 'ic."Of Exemption,you should NEW RESIDENTIAL Pi SQ.FT. TOTAL:
F-' rA become mbject m s oras of the Labor Code,you most
a �
forthwith comply apmvisi. rvsr hi. ermittshall be deemed revoked. BUILDING IEE
a [� 'TRUCTION oNDING AGENCY SEISMIC FEE
I hembyofErm that reisacomtruction leadingagency for the perlamorlosaf
U Z the work for which this A ELECTRIC ME
pcmtit is issued(Su.3099.Civ.CJ
Lemler's Name
TY. MECHANICAL PERMIT FEE PLUMBING FEE
F lender's Address - Q
V Icenify that 1 have read this city
Ai county
and state thin the above information reforms is MECHANICAL FEE
r�" ILL correctlagreemcomply with all cityand caumyordinances and cute lawsrtlatin PERMITISSUANCE
building can.urumion,and herehy authorize reprcsenm0ves of tii
hs city roamer ugmthelhe
zA CONSTRUCTION TAX
L1 Z above-me turrea mpv, forrode inspection nd purposes. ALTER OR ADD TO MECH.
(Wc).gree to save,indemnify end keep harmless the City of Cupertino against
If Jiti Jmenm,costs endenpervseswhi<h may inanyw .crue egvnst andCay
Ciry AIR HANDLING UNIT OPO TO.OW CFM)
conqac ea thegrainam 7pis permit I
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of ApplicaraVContmctor Uatc EXHAUST HOOD(W/DUCn PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 1 W."BTU) Date Receipt#
Will the applicant or future building Occupant start or handle haramous material HEATING UNII'(OVER IW,f)(ItI RTU) TOTAL:
as defined by the Coiasmoo Municipal Code.Chapter 9.12,and the Health and Safety
Cade,Section 25532(id?
C3 Yes El No VENTILATION FAN(SINGLE RISIO)
ISSUANCE DATE
Will thatppliczntorfmurlouldingoccuNn,ueNuipmentofdeviceswhichemit BOILER-COMP CHIP OR I00,04)(1 BTU)
zarfous air contaminants as defined by the Bay Arta Air Quality Management BOILER-COMP(OVER 100,000 BTU) P A I D
Ohial?
❑Yes ❑NO NEW RESIDEN'I'IALMF,CII. SQ.FT.
1 have read the hvallous materials requirement'under Chapter 6.95 of the JAN 24 1995
California Health&Safety Cade,Sections 25505,25533 and 25534. 1 undermost that
if the building does not currently have a tenant,that it is my responsibility to notify the (.
psupant of[lie requiremerx which must he met prior m issuance of a Certificate of Cfn' Ur liUrL 6.
ceupmmy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE
®Y 10300 Torte Avenue
Cupertino, CA 95014
(;i�vltf
Cliperia n o Building Division
(408)777-3228
(408)777-3333 (fax)
WORKER'S COMPENSATION DECLARATION
I 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:
(this action need not be completed if the permit is for$100.00 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 Section 3700 of the Labor Code, I shall forthwith comply with those
rovisions. Date Applicant:
by Section 3700 of the Labor Code for the performance of the work for which this 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.
•
PrinleJ nn Reprletl 1',Lrci
ol,
Cupertino
10300 Torre Avenue
Cupertino,CA 95014
Building Division
(408)777-3228
Fax(408)777-3333
December 4, 1995
Resident
10910 Northsky Square
Cupertino, CA 95014
Subject: 10910 Northsky Square, Permit#27370 - Waterheater
Dear Resident,
According to our records the above mentioned permit has never been fmaled 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
Panted 011 ROC-1610 Poo"