28499 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. O {I
BUILDING PROJECT IDEM'IFICAT'ION o 4
99
BUI INGADDRES':�O O SANITARY NO. APPLICATION SUBMITTAL DATI
Oyy(;,R'S NAMC: PHONE: CONT R'S A LIC NO:
8,1'�ls
t N/C CONTROL#
ARCHTI'ECTM •W LIC NO: ESS: p ❑
CONTACT: - PHONE: X/gRN. BUILDING PERMIT INFO
I ' n _ ❑ Consultant Fees Paid by Applicant(Initial) BLDG CLE - PLUMB MECH
F '/[✓�TLV4 4V ❑
LICENSE NTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby Rum Nal I licensed under provisions of Chapmr 9(commencing )OB DESCRIPTION
"Zwith Section 70(00 nfl)ivision 3 ofthe Business and Professions Code,and my license is
�00 PERMIT ISSUANCE RESIDENTIAL: '
.
,[: in full farce and effect ❑SFDWL ❑KITCfIEN REMODEL
�VU License Class Lich -
1F..,�j a Date - Convector APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
Hjy ARCHITECTS DECLARATION PANELS - El MULTI-UNIT []STRUCTURAL
Z O�Z I understand my plans shall he used as public records MODIFICATION
OZ UPT0200AMP$
P:fat Licensed Professional - ❑INTERIOR ❑CHIMNEY REPAIR
'` OWNHR-BUILDER DECLARATION 201-IIXN)AMPS IMPROVEMENT
y 1 hereby ill the,I nm exempt Earth,Characters License Law for the OVER 1(X10 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
be 0 L V'following reason.(Section 7031.5,Business and Professions Chile:Any city or countySIGNS GLECfRICAI. ❑OTHER .
LLI C which requires a pemtil to construct,alter,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such fambitto file a signed statement L
SPECIAL CIRCUITIMISC, 774
ythat he is licensed paromt mate provisions ofthe Contractors License Law(Chapterel
6� (commencing wall Statham INXBofDivinal3ofthaHirinessand Professions Code)or TEMP.SISTER OR POLE INST COMMERCIAL,
a O yOy� mm he is exempt therefrum and the basis for me alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
R• Section 7031.5 by any applicant for a pt subjects the applicant to a civil penally of POWER DEVICES
H permit []TENANT ❑FOOD SERVICE
t more than five hudr<d...lion(g5W).
[]Lo the amnl Ne pmpeny,or isnot. ededwithxagesastic sole compensmea, SWIMMING POOL ELECTRIC IMPROVEMENT
will do Profession,
C d a:The ate is not Contractors Lice..m o w ca s aril apply .an A nee os ❑OTHER
6,3 end arty wbi.n.ilde:TM ova,la License Low docs not apply to lf owner u( OUTLETS-SWITCHES-FIXTURES
his own who builds or improves thereon,and who Joss such tinte himself or through
his own cmployea,provided that such improvements em not intended or offered for NEW RESIDENTIAL IiLECfR SQ FT.
sale,If.however the building.,improvement is sold wimim.neyemoRomplction,the SQ.FT.FLOOR AREA &SQ.FT.
owner-builder will have the buNen of proving that he did not build or impreve for pun
potential.).
I,as owner of the property,am exclusively convecting with licensed convectors at 1'
convect the projat(Sar.70,14.Business and Profasioas Code:)The Catharines U.
cense Law does not apply to an owner ofpropeny who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a comrations)licensed pursuant to the Contractor's
License Law. It PERMIT ISSUANCE
❑l am exempt.......Sec.' .B&PCfor this reason
ALTER-DRAIN&VCNT-WATER(EA) VALUATION
Ow � Date
WO SC MPHNSATIONDECLARATION BACK FLOW PROTECT.DEVICE
Ih ny nlr nJer.penRIV of perjury.ne ohne following Je<luraions:
❑Ihavemd will noun a Certifiatta of Consent to self-itmuie for Workers Camper. DRAINS-FLOOR.ROOF.AREA. .ON D.
satin.as provider r by Swtion 37M of me Labor Code,for the performance of the •STORIES TYPE CONSTRUCTION
work for which this permit is issued FIXTURES-PERTRAI'
❑1 have and will maintain Workers Compensation Insurance,m required by Section
37M o(Ihe Labor Code,for the performance ofthe work for which this permit is issued. GAS-EA.SYSI C.4 OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number arc:
Carrier. Policy No.: GAS-EA.SYSI' .R 41EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPF.NSA'DON INSURANCE' GRFASP/IND LWA NTCRCEPI'OR
RAP � BUILDING DIVISION
This satd
bot aant be c.mplmed BIN,pRnnil is for..lumcmd dollars(SHE) �- PP.I:S
or leas) GHEASE'1' PLANCHECK
I cenify that in the performance ofthe work for which this permit is ismed,l shall SEWER,SANITARY EA.2(
not employ any person in any mnnner m as to become mbjatto the Workers'Compere ENERGY FEE
z ..tion Laws of C.I fomin.Data WATER IIIATER WNENT/ELL
2 Applicant - GRADING
rA NOTICE TO APPLICAM':If,after making this Cenificale of Exemption,you should WATER SYSTEM? A G _WJG 22 1995
become subject to the Worker's Compensation provisions of the Labor Cale,you most SOIL$EEC
z forthwith .h
comply with such previsions or this Permit all them
dered revoked. WATER SER Iil"ikv, 1101
ur
LUtLM
.7WW CONSTRUCTION LENDING AGENCY, NEW RESIDENTIAL PLMB. SQ.Fr. PAID
U OIhercby.Arta that there isncnnswdiun lending agency for the performance of Dare ReNiptp
U.s t•+ the work for which this permit is issued(Sec.3097,Civ.C.) -
D U Lenders Name TOTAL:
W Lemdds Address '1
1 certify that 1 have read this application and stale Bear the shove information is BUILDING FEE
403 correct.lagme tocomplywithall city and county ordinances and state lows relining to QTY. MECHANICAL PERMIT FEE
U Zbuilding construction,and hereby armorial,reprcuntatives of this city to chairman the SEISMIC FEE
tr abovememoned property for inspection purposbs. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of CLpenin,against ELECTRIC FEE
Iiabilities,judgmems,costs and expenses which may in any way*crime against mid City ALTER OR ADU'1'O MECH.in onsequence of the granting of this permit PLUMBING FEE
APPLICA'- UND kRSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO P0.0 CFM)
MECHANICAL FF.E
SOURC ECUI A'1
AIR HANDLING UNIT(OVER IO,OOfICFht) CONSTRUCTIONTAX
ign* n r EXHAUST HOOD(W/DUCT)
HAZAI US TERIAIS DISCLOSI HOUSING MITIGATION FEE
Will the applicant or future building occupant store or handle hamrd usmaerial HEATING IINIT(TO IINI,"B"TU)
as refund by the Cupertino Municipal Code.Chapter 9.12,and the Health end Safety
Code,Section 25532(.)7 HEATING UNTI7 OVER 100,000 BTU) -
❑Yes ❑Nn
VENTILATION FANfSINGLE RRSIO) PAID
Will life applicant or future building occupant ase car,pmenl or devices which Date Receipt M
mit haaardoes air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100.000 BTU)
District? TOTAL:
Fl yes ❑No BOILER-COMP(OVER IIN),gp BTU)
I have read me hamNous materials requioement under Chapter h95 of me C.H. AIR CONDITIONERISSUANCEDATE.
fomie Realm&Safety Cede,Sections 2,%5G5,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ,FP.
building does not currently have.tenant,that it is illy responsibility to nmify the mcupmt
ofthe requirements which must he met prim to I,,. tt ofa Certificate mOccupancy.
Ownermitchodmdagem Date A ISSUED BY: \\Ir ryC\
OFFICE
• 10300 Torre Avenue
of Cupertino,CA 9500Ci1v- C
14
Cupei thio Building Division
(408)777-3228
(408)777-3333 (fax)
May 8, 1996
Homeowner
10834 Willowbrook Way
Cupertino, CA 95014
Re: Expired permit, (copy attached)
Dear Owner:
According to our records,the referenced permit has not 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 (408) 777-
3228, so we may arrange to extend your permit and schedule a final inspection.
The City of Cupertino requires a response within ten (10) working days from the date of
receipt of this letter. If we do not hear from you within this time,the building department
will have no other recourse but to resolve your permit as expired and discard the records.
Thank you for your cooperation,
Building Department Staff, City of Cupertino
•
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