27612APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELEUMIA
BUILDING DIVISION APPLICATION/PERMIT PLUMBING- MECHANICAL
BUILDING PROJECIA DFINI'IFTCAI[ON
PERMITNO,
C1 i�
o 1 L
BUILDINGADD ISS:
SANITARYNO.
APPLICATIONSUBMITTALDANE
UNIT# , 1.01,#
I_ bAS)
LLLL
OWNERS - �JD{({]fJE'
6QSfJ'T/GI
CO ,/.. IIICC NO: >
SG�Y/C#O� A6<7S7/
N/C
❑
CONTROL#
RCHITEM)lWGINEER: LICNO:
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CONincf S/tEPy � � 1oN 776 7
ri, / e/15 O
QT Y. rI.rCTRIC PERMI9' i7EE
81111 -DING PERMIT INFO
SLUG ELECT PLUMB MECII
PERMIT ISSUANCE
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
1 herebyaffiren that I am licensed under provisiosuofChvprer9 mounmencingwitb
APPLIANCES- RESIDENTIAL
JOB DESCRIPTION
�#��l
C
dS«tion ]000)of Division3 of Ne Business and Profession Code, and my license is in
roeanelltct.
ppNELSfull
Lice
License Class Lic.#
UPT02MAMN
`V
Ilam Contract
201 - IOW AMPS
ARCHITECTS DECLARATION
I understand my plana shall be used m public records.
OVER 1000 AMPS
SQ. FT. FLOOR AREA
S/SQ. FI'.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
I hereby affirm that 1 nm exempt from the Contractors License Law for Ne
TEMP. METER OR POLE INST.
followiallommn(Sectim 7031.5, Business and Professions Code: Any city or county
which requires it permit to construct. alter, improve, demolish, or repair any announce
prior to its issuance, also requires the applicant for such permit to file a signed statement
POWER DEVICES
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter
9(commeneing with Section 7") ofDivision 3n1fNe Business and Profession Code)
SWIMMING POOL ELECTRIC
VALUATION
or that he iseVmpnhetefmm and Ne basis for the alleged exemption. Any violadonof
Section 7031.5 by any applicant for a permit subjects the applicmfto a civil penalty of
OUTLETS - SWITCHES - FlXTURES
t more thmFive hundred
operyars (yempl
n❑ ocheLaswrk, and
nt heslengo yemtendedor ofwed fortheirude compensation,
timmAed or offered tonale(Sec.]M4,9usiness
NEWRESIDINTIALELECfR_SQ. PT.
STORIES
TYPECONSTRUCION
.ndPmhewmk,mult:T1m�mft
anJ Professions Cale: The Com c,,',license Lew does nm apply to en owner of
Poperywhobuil sorimprov th n, and who ork himulfonhroughhis
wn employces,p nide Pro a dedor offeredfonale. If,
OCC. GROUP
RES. UNITS
TOTAL:
however,dtebuil g n erom Yi/M!I^7jIdl �wi
asafmmpletiomtheovirs,
builder will Isv en provin r diJna toldmimproveforpurpt,set,f
(\
QTY. PLUMBING PERMIT FEE
deJ. J
❑ I, as owncndtl popenvl;i:lt, ivelycommatingwithlimnsedcontzacmrsto
FLOOD ZONE
ANN
the project F c. ] , Business end Professions Gale:) The Contractors
PERMIT ISSUANCE
Lmmmot
icense Law Jussnot pplytoanownerol'pmpcny who builds or improves thereon, and
who commetsfor suchprojecrs with a emirmaams) licensed pursuant to the ContmctnrsALTER-DRAIN&VENT-WATER
License Law.
(IiA )
FEE SUMMARY
❑ 1 un exempt under Sec. , B Sr P C for this reason
BACK FLOW PROTECT. DEVICE
OUTSIDE
SANITARY Y N
RSCHOOLTAX
Owner Dare
DRAINS- FLOOR. ROOF, AREA, CONDEcTinti
.
WORKMAN COMPENSATION DECLARATION
YN
❑ Thereby affirm that lhaveacenifcum of comenun selGinsurcmacmoificate of
'Wmkers'Cnmpcmtaion Insurance or a carolled copy thereof (Set. 38M. Luh C.) which
RECEIPT#
FIXTURES- PER'1'RAP
PARK FEE Y N
covers all employee's under this permit.
Policy q
GAS - EA. SYSTEM -I INC. 4 OUTLETS
RECBIPT' #
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
❑ Cerified copy is hereby famished.
GREASEANDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Cenilml ropy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GRL•ASETRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 2WPT.
ENERGY FEE
(This secfonined nut bu completed iffie permit is farone hundred dollars (SIM)
or less)
WATER HEATER WNENTIELECTR
I certify that in the perfomumceofthe work for wbichthie permit is issued, Isha11
not employ my person in any manner so as to become subject to the Workers'
PAID
Compensation Lawsnf Califomia. Dam
Applicant
WATER SYSTEM/TREATING
Date Receipt#
NOTICE TO APPLICANT: If. after making ibis Certificate of Exemption, you should
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
becmrm subjecnnthuWorker's Compensation roosmom oOhm Labor Crile, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
BUILDING FI;H
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hereby affirm that hem is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 301 Civ. C.)
Lenders Name
pt.
ELECTRIC FEE
Lend e
QTY. MSCI IANICAL PERMIT FEE
PLUMBING FEE
�-
I certifyrhy tbm 1 have read this applicminn anJ stem that the above information is
that
cnrtcn. Iagraaxo, lcityai rountynNinancesmd stem lawny
MECHANICAL PET:
PERMIT ISSUANCE
upon
building construction.mJ herebyamhodu representatives vas o(this city menter upon the
and hereby
above-mcan ioned pmpeny for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agrec Raise, indemnify and keep hanluas the City of Catamount, again
I bilities,judgments, cosi madexpenes which may in my way accro gains id Ci
AIR HANDLING UNIT CTO IO,000CFM)
ona seance of the m' is permit.
-AIRHANDLING UNIT (OVER IROM CFM)
nature of Applicant/Conincor am
EXHAUST HOOD(W/DUCD
PAID
HEATING UNIT(TO IW." BTU)
Date Receipt#
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or turn= building occupant stare or handle hazallous mosomiel
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Ifea1N and Safety
HFATEJG UNIT (OVER IM." BTU)
TOT
Cafe, Section 25532(a)]
❑Yes 1:1 No
to
VENTILATION FAN (SINGLE RFSID)
Willthe applicnm mfuturebuildingoccupam uuequipmem ordevitts which emit
haem ous air comm umaids as defined by the Bay Am Air Quality Management
District?BOILER
BOILER - COMP OHP OR 1100,00) BTU)
s� ISSUANCE DATH
(t.7 z.
- COMP(OVER 1W,000 BTU)
❑Yes Cl No
I have read the haza sous maurinls requirements under Chapter 6.95 of the
ia Health & Safety Code, Sections 25505.25533 and 25. l understand that
Californiath
n p
C�Ty Gh R ®1/���
V A'7
NEW RESIDENTIAL MECIL SQ. FT.
Film building does n"I currently have a tenant, that it is my responsibility to notify the
occupant of the rcyuirements which must be met prior to issuance of a CerTlicate of
L
Occupancy.
ISSUED 9Y: �y\1
Owner m amhmized agent Data
TOTAL:
OFFICE
10300 Torre Avenue
Cupertino, CA 95014
Building Division
(408)777-3228
Fax (408) 777-3333
December 4, 1995
Resident
22167 Wallace Drive
Cupertino, Ca 95014
Subject:22167 Wallace Drive, Permit # 27612 - Repipe
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.
Sincerely,
City of Cupertino
P,inted on Pecydea Paper