26423 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO Bull trill.Pi,RL'IRTf,A. PERMIT'NO.
BUILDING DIVISION APPLICATION/PERMIT 1'I1UMTNG-MF.CHANICAI. LJ
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS' 7 I p SANITARY NO. APPLICAT
ION
SUBMITTAL DATE
I 2 / s s (,/ 1c,UNIT# LOIN �. /{yam
OW NA : U'IO CONTRACro NAM&y. LIC NO: N/C CO`NTRO`L `
A CIIM /ENGINEER: C•• LIC NO: r ADDRESS: ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
LDG ELECT PLO MI:
PPRMIT ISSUANCE
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL ION
paZ I hereby uffinn that Ism licensed undcrpmvisionsofChapter9(commencingwith ��
OO Sraion]tNXp df Division3o(the0minas and Professions Cade,end my liccruc is in PANES rn
full fxom m d effect. IIP TO /I on
w
ZZ iy License Class Lia# WRS"iV
r!itQy Date Convector 201.1000AMPS
Z0 z ARCHITECTS DECLARATION SQ.FT.FLOOR AREA siSQ.FT.
OZ�Q I understand my pions shall be used ns public records.
F' OVER IOOOAMPS
rn sp.2� SIGNS ELECTRICAL
� ,Y� Licensed Professional
c' OWNER-BUILDER DECLARATION SPECIAL CIRCUR/MISC.
y U I hereby affirm that 1 am exempt from the Contractor's License Lew for Ne
u13 LL yQ following reason.(Section)031.5,Bmaincsx end Ikolessidns Code:Any city or coumy TEMP.METER OR POLE INST.
s200J which requires ap.it to consovn,.her,improve,demolish,or repair any structure
Y� prior to its issuance.alsorequires theapplicant fm such pared,to filesaigned sutanent POWER DEVICES
<p that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
p•g o�' 9(commencing with Section 7000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALU
m m that he is exempt therefrom and the basis fomhenlleged exemption.Any violation of
Y Smion]031.56 1 OIITLEfS-SWITCHES-FI%li1RE5 `se
FZ eoundop applicantfor subjects applicant Pendryof
X50 n vhun livehundrcd dollars($Sip). NEW RFSTDENTIALELECIR _SQ.Ff.
tivyvyl�l, 1, sowneroftheproNny,urmyemployeeswithwegessuheirsolecompcmNon, STORIES TYPECONSTRUCPTON
L w I the work,and theswctureis not immtudedornffered faradic(Sm.]044,Business
Professions Code:The Contractor's License Law does not apply to an owner of
IF party,who buildsmimpmves dcrean,and whodoessuch work himselfomhroughhis
oatdmnd,mw,providedthatsuchimpmvamenu ere nm imendedoraf(eredformle.If, OCC,GROUP RES.UNITS
however,the bulldingor improvement is sold within one year ofcompletion,the owner.
builder will have the burden of proving that he did not build or improve for purpose of
m1eJ' QTY. PLUMBING PERMIT FEE FLOOD ZONE. MIN
con❑ Las the pmj l(Sec.ny,am Business
and ontrecdng wiCod I edcommetors a
License Law
the project(Sec.]004,Business endy who builds
Cod p The Contracmr's
whormlmets fosnm apply to shwa rnfproperty whosed puorimprovenhrreon,anA PERMIT ISSUANCE
whocomow. such Prejcctswithecontnctor(s)IiunsW pursuanuothe Convenors ALTER-DRAINA,VENT-WATER(EA)
I.icenae
Low. FEE SUMMARY
❑ 1 in exempt under See. ,B&P C for this reason BACK MOW PROTECT,DEVICE: SANITARY CUTS I Y T L N
Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOLTAX YN
ClIhereh rdfiLthm l have acenifica¢ofconsent mself-insure,macenifcamofRECEIPT'#
PIX•I'l1RFS-PER TRAP
r WorkesY Compensation lnsumnm oraccnified copy thereof(Sm.3800,Ln C.)which PARK FEE Y N '
covers all employee's under this permit. GAS-HA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Policy# BUILDING DJVjJjQN FETES
Company
❑ Certified copy is hereby fashed. GAS-EA.SYSTEM-OVER 4(EA) PLANCIIECK FEE
mi
❑ CenifiW wpyiv fled with the city inspection division. GREASNINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
This section need not becompleted if Ne permit is for one hundreddollim(5100) SEWER-SANITARY-STORM•HA.2 T. ENERGY FEE
or less)
I cenify that intheperfommnceofthe workforwhich thispennit is issued,lshall WATF.RHEATERWNENT/EL
dot employ any person in any manner so as to Immune subject to the Workers I PAID
CompcmNon6awaof Califomla. Date WATER SYSTEMtTREATINODam Receipt#
O Z Applicant
2 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEWRESIDENTI B. TOTAL:
p-t become suhject to the Worker's Compensation provisions of the Lahr Cade,you must
ta-' > forthwith comply with such provisions or this permit shall be,deemed revoked. BUILDING FEE Iy
4 (� CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that them is a construction lending agency for performance of T
U O the work for which thia permit is issued(Sec.309],Civ.C.) ELECTRIC TEG
LT. Isnder' Name PLUMBING FEE
Ic
H Lender'sAddress Q'I'Y. MHCIIANICAL PERMIT FEEL) enify that I have read tirl aPPOcaion and aim Nat the aboveinformationIs
acorrect. legmc mcomply with all cityand county oMinoncen and stem laws rclmingm PERMIT ISSUANCE MECHANICAL FEE
_ ,,0 building construction.and hereby amhorizetepresenudvesoffthiv city m enterupnn the CONSTRUCUONTAX
U Z A,we-memloned property for inspection purposes. ALTERORADDTOMECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
lindides,judgrants,costsand expenseswhich maymanyway ace regains,so. City AIRIIANDLING UNIT(TOIf,dMCFM)
in aequqvofth rani of shis \/IV�w
AIR HANDLING UNIT(OVER 10,0110 CPM)
Sign rcof Ap ,can Commcmr am EXHAUST HOOD(W/DUC) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNITfTO 101L0(g,BTU) Date Receipt#
Will the applicant or future building occupant store or handle hszardam materiel HEATING UNIT(OVER 101,000 BTU) TOTAL:
as defined by the Cupenino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(a)'1 VENTILATION PAN(SINGT.E RESID)
ElYes ❑No
Will The applicunmr fmurc building occupam use cquipmenmr devices which emit
BOILER-COMP QHP OR I W,000 BTU) ISSUANCE DATE
lverdous it conuminoms ss defined by,he Bay Arca Air Quality Manugemem BOILER-COMP(OVER Io0,00)BTU)
9istricB p a
❑Yes ❑No NEW RESIDENTIAL.MECIL gQ.Pr'. P 4"1
I have read the hazardous materials emitiremems under Chapter 6.95 of the za„��
it lifnmie Heahh&Sefery Corte.Section it to 25505at it
yit trepa34. Iundenund the, W 25 199
D'@e building a re nm currently have a st he the it is my mapnce oiliry er amity the k�
cupam of the reyuirenmme which rens,he met prior m issuance of a Certificate of
Occuponcy. C.• �
U IBJ
Owner or authorized agent DaeISSUED BY:
OFFICE
Cupei-thio
10300 Torre Avenue
Cupertino, CA 95014
Building Division
(408)777-3228
Fax(408)777-3333
September 26, 1995
Dolores Koser
10421 Pineville
Cupertino, CA 95014
Subject: 10421 Pineville, Permit# 26423
Dear Ms. Koser,
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. &lQ
Sincerely,
City of Cupertino r
0
r':'in12d ;n i9ec1'cleq Y,ivar