27067 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOoILAIIN's-RCEC MICA L PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL, n O
BUILDING PROJECT IDEYG
I'IFICATION
67
BING+DDRESS: SANITARY NO. CATIONSUBMITTALDATE
4. \
F n `
C 0"l UNIT# LOTH r
OWNERS NAME: a s PHONEACfOR'S NA P.' LIC NO:
N/C CONTROL#
I
RCUTEC'ElEtIGINEER: LIC NO: DDRESS: ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT CLUM11 :C
PERMITISSUANCE _s
LICENSEDCONTRACTORS iomofDECLARATION APPLIANCES-RESIDENTIAL
p00 Iherebyd Division
Licensed tendorprovirofessorateCom9(cammencing sI. LOB DESCRIPTION
ts100 Sectionrceand of UivisionJ of the Businwsend Professions Code,and mylicroseum ppNpg
tF� full fusee end affil.
FZ�Z License Class Lic.p WTO 200AMP5
r
Ma, Dalt Contractor 201-1000 AMPS
Oyr, ARCHITECT'S DECLARATION
ZOVER 100D AMPS SQ.FT.FLOOR AREA S/SQ.FT.
020 Iundcrsmnd my plans shell be used Public words.
< �,,j SIGNS ELECTRICAL
W W E,4 Licensed Professional
�y�tt< OWNER-exempt Ecan,heContacDECLARATION SPECIAL CIRCIII'1'/MISC.
Sec5�OWIVF-.. 1 hereby affirm Ihm 1 sonER BUIL from the ctofe I.iuwe law for Ne
of 3 4 m following reason.(Smtinn 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE MST.
(3 which requires.permit 10 conswct,idem,improve,demolish,m repair any ewetum
YI prior 1.it,issuance,also mcpmmas theappdicamfar such pewit to filen aignedsmtement POWER DEVICES
G p that he is licensed pursuant to the provisions of the Contracmr's License Law(Chapter
a G 9(commencin with Section 7000 of Division J of the Business and Professions Cade SWIMMING POOL ELECTRIC
o{y commencing ) ) VALUATION
or I—Z❑ Section
h7031.5 by any applicant
nt f the bmisfmthe is thedexemantto AnyviolationPrimiry of OIITLEI'S-SWITCHPS-FI%TURES
Fy5^ Section than byanydyed doltfarapewit subjects the applicant acivil penalty of
nm mart Nen five hundred dollar($500). NEW RESIDENTIAL ELECIR S .FT.
y ❑ Lesowneroftheproperty,ormycmployttswith wegeaestheirwlecompensadon, —SQ.F17. TYPE CONSTRUCTION
Eprop
will dothework.end the stacturcisnotintended orafferedfor sale(Sec.7044,Buriness
and Professions ldsorimprover
pr Convector's License Law does rat apply ro as owner of
own enywhees,proorimproveech improandwlvarm notch work conf sedthroughhis OCC.GROUP RFS,UNITS
awnemployees,lding of i that such improvementhin not intended
mpletircd foruu.If,
huwevea the bve be
rdeprovementiahat he id noneyem or impose Torp rpomeo- T
builder will have the burden of proving that he did not build or improve for puryou of a
le.). QTY, PLUMBING PERMIT FEE FLOOD ZONE (k APN
❑ hasawnerofthe propcny.am exclusivelyconwctingwith litrnsedconwcmuto \\
construct the project(Sec.7014,Business and Professions Code:)The Contactors \ '
License Lawdoes nuc pplyu a with
afpmpcn)whnsedpaorimpm theContracend PERMIT ISSUANCE 7
whence Law.for such projectswithecamrumor(n)licensed puuuanstmhe Cnnvaanr's ALTER.DRAINA,VENT WATER(EA) Ir
License Law. 6 (� n .'LSU ARY
❑ I em esempt under Sec. ,B Is P C for this reason ) c_
BACK FLOW PROTECT.DEVICE SANITAR Y d
Owner WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR.ROOF,AREA,COND. SC Y IPf# am"N
❑ Ihcreby effiw tharihavea¢rtificam of conxmwxif-insurt,a.attrdficmeof RECEIPT#
WorkersCompensation Insurance ore citified copy thereof(Sw.Jggl,Lab CJ which FIXTURES-PER TRAP 1 E YN
covers all employee's under this pewit OAS-EA.SYSTEM-I INC. OUTLETSL ass— RECEIPT#
Policy N BUILDING DIVISION PEGS
CI
❑ ConifieGAS-M.SYSTEM-OVER 4(EA) PLANCHECK FEE
Certd copy is hereby famished.
❑ Cenifed copy is filed with the city intention division. GREASE.rINDUSTRLWASTF.INTERCEP1DR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
This section and not be completed if Ne pewit is foronehundr>d dollen($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEB
m leas.)
I certify that in the perfowancm of the work far which this pewit is issued,I shall WATER HEATER W/VENT/ELEM
not employ any promn is any manner as a to become subject to the Workers' PAID
Comprpostionlaweof Califomis. Date WATER SYSTEM/IREATING Date Resciptof
0 Z Applicant
z0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLAEL SQ.FT. TOTAL:
''rV) become Subject to the Workers Coordination provisions of the labor Code,you must
CCs ' forthwith comply wi lh such Provisions or this pewit shall he deemed revoked. BUILDING FEE
s CONSTRUCTION LENDING AGENCY SEISMIC FEE
z
I hereby effort that then is a consouctiun lending agency for the performance of ELECTRIC FEE
V C) the work for which thin pewit is issued(Sm.3097,Co.CJ
leaders Name
IT. F lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
L) 1 mnify Nat I have rtW this application and sure tet the above infawedon is
0. current.Ie gree to comply with 0l city and county oninenms and nam Iowa relating to PERMIT ISSUANCE ' MECHANICAL I NE
FEE
building construction.and hereby amhuriu representatives alibis city to emerupon the CONSI'RUCTIDN TA%
V 7 above inalio and property for inspection purPoses, Al MR OR ADD TO MECH. !�
F7 (
We agree to save,indemnify and keep hewlesa the City of Cupertino against
liabilities,' dgmems,cost and expenses which may in any way accmeugairulsaid City AIR HANDLING UNIT(TO 10,000 CFM)
in con. fibs Funding o"is
pe wit. AIR HANDLING UNIT(OVER IO,gp CFM)
Siynatureof ApplicardWonwctor De EXHAUST HOOD(W/DUCn
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the o mlicont or Town building occupant same or handle huaardous material IIL=ATING UNIT(OVER I 00,00k,BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(gT VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
BOILER-COMP AHP OR 100,11(10 BIL) ISSUANCE DATE
Will air co poaut o ds as building by the ay Area it Quality
a �
.haaerdous dr contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER IW,ODO BTU)
JivuimT b_
❑ad ❑No NEW RESIDEN IAL MECH. SQ.I9'.
1 have read the fetyCode.mctionss requirements under Chapter understand
of the 04
if the
uil Hgdoes of cur ntlyhae Sections 25505,M533it is yrosixroul 34. 1undenotif that t� s
ifthebuildingdoesnotmordsw have as.N, teed is myrtuance billy tonotifythe
accup an of Ne mluircmenu whish must a and prim u issuance of o Cenificeu of r our C�
Occupancy. GII\ �
Owner ar uuthnriud agent Date T ISSUEDB .
0 �C
Corinty of Santa Clara C'OLII �.
13uIIdIlIg In."pec:linn UIII(v
•nlnu) tl(lv(•rnn N•nl C(•nd•r, linsl N'In I
n\PI;til 11(•(11 llnl;till rrl s7 IB:u..`..Q'•
sial hw(•. (:;Jlltn1da U61 In
p111fl12!1!I-2.111 FAX 27!1-Hr,3
July 20, 1994
Tina Hubbard
Fox & Carskadon
20514 Saratoga Los Gatos Road
Saratoga, CA 95070
Subject: Building Permit Record Search (94179)
Site Address: 21853 Monte Court, Cupertino
Assessor Parcel No.: 326-19-074
Owners Name: Theodore D. & Janice Lassagne
Present Jurisdiction:" City of Cupertino
• Bldg. Permit # Date Issued Description Status'
45222 11/04/55 Residence & Garage Completed
54499 11/05/58 Addition Completed
08058 1/09/68 Second Story Addition Incomplete
Ve y truly s,
HOM S-SHIH,
Building Official EC I VE
Attachment , P 22 �Y J
"Please see other side 19w
OLOG' INSPECTION DEP4uTAjFjM
CITY OF CUP jM�
• FEE COPY
IS(rml((I tial n•rvltinl v: Nirl l:u•I fit. I lnn(1;1. %(u• I�tly;irn. linll(i.n¢nli;v, IAnI UiliJun, ninnno Ak4G•nntl
•om
COMPLETED: The project has received a final inspection by this
office.
INCOMPLETE: The project has , not received a final inspection by
this office. If the last inspection was made more
than six months ago, the building permit will have
to be renewed by the owner or his agent.
JURISDICTION: If the parcel was annexed to a city, information
regarding construction will have to be obtained
from the noted city.
NO PERMIT: A building permit has not been issued by this office
for work at this address. In order to legalize
• construction, the owner or his agent has to apply
for a permit for the work. For more information,
please ask for a building permit informational
handout.
PRIOR TO 1947: Building constructed prior to 1947 were not
required to have a permit.
•
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DO -NOT, WRITE IN SHADED AREAS.
(IIFCK IIERE IF •YOU NEED A COPY P.C.N:1 (U)
t �I 'IIQ �I II 'ti Or
Of THIS APPLICATION IN ADDITIrON
I S��Iv'^ V 1� v I�j ��1 iI 1rN •y���� r(� .':! fl II-' l• I'
10 YOPERMIT RECEIPT LJ vvv.YR.v,:q inI) ,. F f -i1 ..-(. r-. � M- J 1t
PERMIT REOU UNDER FIGOD CON If Y 111 I 1 1 rc "
IROI DIST ORD 59.1
FIRMIT FULL II y�yP �A Il T Cl�ll )i ltD�t PON n,ryCIq!YALIDATION
YES U NO EA/e�O � LL1N __ 1 l� J I�V \�!-LL.l LL41•-�.L� -+N-
to oalormny wIlh the p,oYldens of Senlon 7031 5 of The BVdpCD and Profession,
rt _ _IRE.•fT�d�s'_pB_NOIIID_ _ ___
C dv and SnOns JB00 0l Labor Cada of the Slate of California. pppHca01_13U,01_13U,nl ,ha01_13U,IN:
ul
Idv w'Ih the RWlding Impactor the «rllRmle,, dmipnorod In 111 and 171 below and/or _- - L , �J . I
shn 11 Indicate Rem 131. 141, 151 TAI hi,h,,, 1, ap,llmbly. - -'
PI CMIiLm,e of Consent o1 Shcdmu,ed Issued by Ihe Sipple, of Ihdmniol RclnHonF, 1, 1 "1 / / bAY.,
171 C.,,.Pwi, for 1•.a[I cippRmle repYl of WeAmen m
A Cempen0en Insurance Issued - V 1\/
by on pdmRled Insurer L
er. _
UI The curt of the wort lO be Performed 1, $100 or I... HUALTI� 1' UY
I��•1 Int 1 rmU1y rho,In the pedmmance of 0M-Pnk for vi Ohl, Pvrmll H Issued
I TC I Ihol 1 ,hall nor employ any prison In ony manner ,o at to become subject
, - In the Wo,Smen, Compenmlwn Lewf 01 California. OAYU
151 1 -Id, marm
bar rhe aPNlnl i, helen
d under The provI , of Chaplor 9
r - "
I,or,,rng r Section 70001 of division 3 el The Business and
Pmlewam Codr, and Paid m,phcmn s California Slate Contracted license •ori'
Z.°1, VNb.p NVIC6!4GL U
;/,��Ia,YhcallOn H In fall force and oiled
f - 1 161 APpOmm b Psiampt Isom t e C.a under t Or n.. L.W. I.fin b Provisions of DAT
I 1 Seceon 7040 Ihmugh 7057 0l the CommDori koma Le ,o15Totn bad, for
eTempLOnl _
, [/ PLANNING DEPT--' DY
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Gruel - I-S !n�'
gt
APPUIT 31 S' 'I
COMPENSATION CERTIi KATE VERIi1LD _ y1RR NATIONAL UY
THIS APPLICATION IS A BUILDING PERMIT WHEN PROPERLY FILLED OUT,
SIGNED, AND MACHINE VALIDATED IN THE SPACE PROVIDED. OATC
PERMISSION IS THEREFORE GRANTED TO DO THE WORK INDICATED
BELOW IN ACCORDANCE WITH ALL APPLICABLE ORDINANCES, LAWS OTH'tq pr
AND REGULATIONS.
7'UTCTeT CES 1^S) [Qti4c^;ITXc IGFs' '1 Y'-I4:7Rlt;J DATe
NNAIRr O5 8 APPLICANT, DD NOT WRITE IN SHADED _ __ INSPF.CTION RECORD
UU AREAS- BEAR DOWN -
PRINT OR TYPE .THE 2nd COPY IS YOURS DATe 17411CrO R[MARNn
/'� APPLICATION FOR BUILDING PCRMIT 1. FOUNDATION FORMII 1�- I -, _ , • .l . _ _
l 1 COUNTY OF SANTA CLARA -�PIIM --- - y- -- ---
��\/// _ POUR NO CONCRETE UNTIL THE ABOVE HAD BEEN SIGNED
BUILDING INSPECTION DIVISION -- - - --
70 WEST HEDGING SL • SAN JOSE, CALIF. 95110 • TILFPHONF 290.2351 !._HCAT,NG DUCTO I
LO1A110N A.COMFORT COOLING
Lnr aLOCX TRACT � 11 a1ROi'p \
nFL T e AAnanr+.,— (/• ❑O NOT COVh.R FLOOR.^.UNTIL THE ABOVE HAS BEEN SIGNED
_ r_ _?•�__1r �(T�%Y'-�1;T IIf� 11 _tet"C C LONG UCAMU (CONC. ULXI
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Cap','.nlneEr HbUu1T rLull.
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C _F _ ___ _ DO NOT WIRE UNTIL THE AEJOVE'HAO BEEN SIGNED
Zllt'NIfFCr ONI
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CeCTHIC WTRINp Ir T
_[NpINEEP _ ���✓"e{I"�f>�/?R_y�d' ___ �_, 1 1
COMPACTOR LIC Np. COVC 1 NO WALLS UNTIL THE ABOVE HAD BEEN SIGNED
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