26662APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO B ILIBNG—hLKL7Ri AL PERMI"f NO.
APPLICATION/PERMIT PLUMBING - MECHANICAL X 6 6 2
BUILDING DIVISION IIIJII.DING PIiWP,CT IIIEN'I'IPICA'I'ION G U o o L
CUNT AUL PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB ECH
'1'Ol'AL:
PERMITISSUANCE
El ❑ ❑
pyZ
4100E
yFVU
FZ ty
mQy
F�ARCHITECTS
0z O M
F m
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that l am licensed underprovisiomo(Irepter9(commencing with
Section ]00(0 of Divi Pfgphe Bminess;dPmfessions Code, and my license is in
full l'n¢e ante t. L' � 9�S
I.icen lass _ �. # 7
Dde Comm
APPLIANCES - RESIDENTIAL
2 IDR DESCRIPITON
•L J�
PANELS
UP T021gJAMPS
201-I"AMPS
DECLARATION
I understood my plans shall be used as public records.
OVER IOIIOAMPS
SQ. FT. FLOOR AREA
S/SQ. FT.
SIGNS ELECTRICAL.
Licensed Professional
F17E SUMMARY
a�a'6
K,03µ
cull
0.¢.1
W�i n
�M O
d4op'
OWNER -BUILDER DECLARATION
i hereby affirm that I nm exempt from the Contractars License Law for the
following reason (Section 71131.5, Business and Pmfessiuns Cute: Any city or county
which requires a permit to construct, after, improve, demolish, or repair any stmcmre
prior to its issuance, also requires the applicant farsuch permiuo file a signed statement
that he is licensed pursuant the provisions of the Contractor's License Low (Chapter
9(coomeaming with Section7DW) of Division 3 ofthe Businessand Professions Code)
SPECIAL CIRCUIT/MISC.
OUTSIDE
SANITARY YN
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELEMIC
VALUATION
iW _rn
H Z Q
p,
moat he is exempt therefrom and the basis for themlegN exemption. Any vimbino of
Seoion 7031.5 by any applicant for it subjects the aPpI canna a civil penalty of
non more than Eve hund¢A dollars IS �I
❑ Lasownernfthc prol���''rrrttt�Iy'' rm m nyces a sfoeirmlecomperaation,STORIES
will du the work, and Ne st caded salelSe,7(AUBusmr.
❑ I herebyaffirm that l have aceriif¢ateofermsentto self-Insum,ora ccdificatoof
WorkersCompensation lnsuranceora cramfied copy thereof(Sec. 3800, Lab C.) which
OUTLETS - SWITCHPS - FIXTURES
NEW RESIDENTIAL P.LECTR—SQ.FT.
PARK WEE Y N
TYPECONSTRUCTION
ers efor nyec' t' L
Policy# TSI•
and ProfGtslanf Code: Uhe i• fs License IAxx�f does not apply to an owner of
BUILDING DIVISION FEES
Company
❑ Candied copy is hereby famished.
XCandied copy is filed with she city inspection division.
GAS - FA. SYSTEM OVER 4I FA)
own mp11F�'3yhlfut suchimm8nts urenotimendW arof(eredforsale. I(.
....a.. ortvvr
ora.um sn
'1'Ol'AL:
h wevcr,t it prpey S del• Ihin oneyoar oFoomplwion, lhavwneo-
howev will eb(See rk �rsN(ng that he did not builtl orimprove for puryosc of
VJJ
QTY. PLUMBING PERMIT FEE
mi`')'
❑ I, as ownc ❑ epropcny,am exdusivelycammcting with licensed cammcmmo
FLOOD ZONE
APN
I nnetrud the pn t (Sec. ](144, Businexs and Rafemions CaJ<U The Contractors
cense Law Jocsnot apply roan ownentfpropeny who builJsnrimpmvesshereon,and
PERMITISSUANCE
who commis farsuch projects with a contractors) licensedpuamool mshe Commam a
License Law.
ALTER - DRAIN & VENT- WATER (EA)
F17E SUMMARY
❑ I nm exempt under Sec. , B & P C for this reason
BACK FLOW PRO'1'ECT. DEVICE
OUTSIDE
SANITARY YN
Owner Dete
WORKMAN COMPENSATION DECLARATION
DRAINS - FLOOR, ROOF, AREA, COND.
NECI311T#
SCHOOLTAX YN
40
❑ I herebyaffirm that l have aceriif¢ateofermsentto self-Insum,ora ccdificatoof
WorkersCompensation lnsuranceora cramfied copy thereof(Sec. 3800, Lab C.) which
RECEIPT#
FIXTURES-PERTRAP
PARK WEE Y N
GAS - HA. SYSTEM -1 INC. 4 OUTLETS
ers efor nyec' t' L
Policy# TSI•
RECEIPT#
BUILDING DIVISION FEES
Company
❑ Candied copy is hereby famished.
XCandied copy is filed with she city inspection division.
GAS - FA. SYSTEM OVER 4I FA)
PLANCHECK FEE
GREASEIINDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS
GREASETRAP
SOILS IEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM PA. 20OFF.
ENERGY IEE
(This section need not be completed tithe permit is forone hundred dollars IS 1110)
or less.)
WATER HEATER W/VENT/P.LECTR
I cenifydr.,inthe perfanname m flu, work far which this permit is issued. I shall
not employ any .on in any manner so as to become subject to the Workers'
PAID
WATER SYSTF.MfrREVDNG
NEW RESI DENTIAL PWB. SQ. ff.
O Z
Z 0
Compenmtiou Lawsof Culifomia. Date
Applkamt
NOTICE TO APPLICANT:If, after making this Cenificut of Exemption, you should
Date Receipt#
TOTAL:
LI)
I;
become subject .,he Workers Camperemic r Provisions of the Latin, Cade, you at
forthwith comply wit such provisions or this permit shall be, deemed revoked.
BUILDING FEE
SEISMIC FEE
W Q
2
V O
CONS' I' RUCTION LENDING AGENCY
I hereby uffinn thin the. is a achmenction lending agency for the pe,fa.. of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lamar's Name
TOTAL:
ELECTRICFL•E
Larder's Address -
-
QTY. �_7 MECHANICAL PERMIT'' }" FEE
PLUMBING FEE
U
U
U Z
I codify that 1 have mad this application and state that Ne above imformetlan is
correct. l agree to comply with all city and county ordinances andstam laws rending to
building construction, and hereby amhurize representatives ofthis city to enter upon the
darvemoentioned property for inspection purposes.
PERMITISSUANCE: -
MECHANICAL FE oe—
ALI'HR OR ADD TO MECII.
CONSTRUCTION TAX
(We) agree to save, indemnify and keep hamdcss the City of Cupeninn against
Iiabilities,juJgmenes,cosu andexpcnscs which may in any wayaccmeagamss said City
AIR HANDLING UNIT (TO 10,000 CFM)
insegnence of the gyntlngthno com,
AIR HANDLING UNIT (OVER 10,000 CEM)
S' nature mApplicamiConlmcmr Date
EXHAUST HOOD(W/DUC)
PAID
HEATING UNITt]'O IfX1,1100 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Raeipt#
Will the applicant or fultre boildmilevcopart store or handle hexamim,material
as defined by he Cupertinoas
Municipal Ce, Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER 100,0100 OTU)
T01'AL:
VENTILATION FAN (SINGLE RFSID)
Code, Section 25532(a71
EI Yes 11 No
Will the upplommorfuluro building occupant usecluipment nrdevices whichemit
BOILER- COMP (311P OR JOB001 BTU)
ISSPNAf PATE
#y 1)District?AIQy
BOILER - COMP(OVER 100,000 BTU)
.hazaoconformationsi
rdair conformations as definN A. by the Bay AAir Quality Management
❑Yes 0 N
_ 2
1995
NEW NESIDEMfIAI. MECH.—SQ. FT.
1 have read the hazmdous materiels ralumments under Chapter 6.95 of the
ing lthdo & Safety Cade. acetone 35505, 25333 and 25534. 1 understand that
if the building J«s not mount, t itFn is myssum responsibility m notify the
if taparm
have awhich
eery (),C. CUP&,
C
cc of d madscurrently
nu
ant of d¢ reyuirmnunts which anter Lro con prior Ice issuonca of a Certifiane of
,
a
Occupancy.
ISSUED BY:
Owner or authorized agent Dole
TOA .�
Cit}- of
Cupertino
10300 Torre Avenue
Cupertino, CA 95014
Building Division
(408)777-3228
Fax (408) 777-3333
December 4, 1995
Resident
22740 San Juan Road
Cupertino, CA 95014
Subject: 22740 San Juan Road, Permit # 26662 - Two Furnaces
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
is
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.
0
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 „ 0„ n
Printed on Recycled Paper