27370 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO REd,llIPAJ-L-IAL(RICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 27370�QJ�O
BUILDING DIVISION BUILDING PROJECT IDF.N'I'IFICA'I'ION'
BUILDING ADDRESS SANITARY NO. APPLICATION SCENE 19'AL DATE
I/ UNIT# LOT# 2_(L�}.� C
OWNERS NAME: PHONE: CONTRACTOR'S NAME: LIC NO: Vf l J
(J1` K 114mr / I! OC-l6-.3 N/C CONTROL#
\RCHr [C'I'/ENGINEI.R: LIC NO: ADDRESS: ❑
-Orli Nz.A OwD U
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
_ BLDG [LECA PLUMq IL.
P � — 90 0 PERMIT ISSUANCE
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL, lOB rt'tCRIpTION
�y7 IM1crebyaO im+Natl 3 of
fdansedunss and Proan ions,Code.and
ommccense with
O_O Smsiohembyof Division wl=l da,Businessand i.siossof apta9(co mylicense is PANELS
full force and effect. `
FyyVj License Class Lic.e UPT02MAMPS
m D y
Date Contractor 201-1000 AMPS SQ.]in FLOOR AREA $/SQ.PI'.
!-yz ARC]IITECPS DECLARATION OVER TBBBAMPS
z O v I understand my plans shall be used as public records.
P L H W SIGNS ELECTRICAL
Q 7 j Licensed Professional
�S4pt< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
OW1 thereby affirm that I am entraps Gum the Crouton,',License Law for the
4134.y fallowing reason.(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
which requires a famous to construct.after,improve,demolish,in repair any structure
}� prior to its iamince,somquires tbeapplinm Boesch Pesmiuo fileasignedstammem POWER DEVICES
C Q shat he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
ySWIMMING POOL ELECTRIC VALUA'110N
6y� 9(commencing with Section 9((p)ofDivisionJof the Business and Professions Code)
W❑ti or that he is uxcmpnherefrom and the basis for Nc alleged exemption Any viNatlo.nf
y any applleam for a Permit cub cm the T IITLITS-SWITCHES-FIXTURES
F-Z Q Section 9th1 5 h je PP icwt m a civil pcnallY of i�
not more shen five hundred dollars($,flo).
K�o ❑ I,asownerofNepmpcny.ormyempluymswiN wages uxtheirsnlecampcnmsion, I NEW RESIDENTIAL ELECIR _SQ.FT. STORIES TYPE CONSTRUCTION
i3o0 willdothe work,and she suucmm is not intendedoraffered forsale(Sm.7044,Business
and Professions Code:The Commetors License Law docs not apply m an owner of -
property who buildsoflmproves thereon,and whodaes such work himselfor through his
employ¢s.pmvided that such improvements an not intended proffered forsale.If, OCC GROUP RIiS.UNITS
M1builder will have the burowever.the but lding or improvement is sold within one year ofcompledon,the owner. O A
den of proving that he did not build or improve for purpose of
sale)' PLUMBING PERMIT FEE
❑ Las owner ofthe progeny,am exclusivelyconmQTY.
acting with licensed contractors to FLOOD ZONE APN
ge
moms,the pr jcct(San.91144,Business and Professions Code:)'The Cantructods
License Luw dcasma.p,ly tounownernfpro,ri,who buildsmimproveslherem,and PERMIT ISSUANCE
whormracrs foranch projects with a contractor(s)licensed purmanto the Contractor's
License Law. ALTER-DRAIN&VGNT-WATER(EA) FEE SUMMARY
❑ 1 am exempt under Sec. .B&P C for this reason BACK FLOW PROTECT.DEVICE OUTS I FLFS
SANITARY V N
Owner Date ONAINS-FLOOR,ROOF,AREA,COND. RECEIPTN
WORKMAN COMPENSATION DECLARATION , . SCHOOL'TAX Y N
❑ I hereby affirm that l have acenificamofwnsennoself-imum,moreificate of 1 FIXTURES-PER TRAP RECEIPT#
Workers'Compensation a
Compensation lnmnce crcenifed copy,shereaf(Sm.39W.Lab C.)w,he l PARK ME V N
covers all mPnYees undenhis pcmrL GAS-FA.SYSTEM-I INC.4OUTLETS RECHIPT#Policy If BUILDING DNISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cenilieticopy is hereby famished.
❑ Cenifcdvpy is filed with the city inspection division. GREASEANDUSTRI.WASTE INTERCEPTOR GRADING 1tiE
CERTIFICATE.OF EXEMPTION FROM ORKERS' GREASETRAP SOILS FEF, a
COMPENSATION INSURAN
(Thi.,,ce:onncednnlnccompletqf the he, nitf on hundreddollars($NN)) SEWER-SANITARY-STORM EA.200PT. ENERGY FEE
cis.)
I cenify tbotin the pmrfnnnancc of the work for thixpermiti ' uM,lshall WATER HEATER W/VENT/ELECI"R
ran employ any person in any manner so as me s bje Workers' PAID
Compensation Wwsof Califomio. am co WATER SYSTEM(IREATING Dae 'cipt
Q z ApPlicunt
z C) NOTICI7TOAPPLICANI':I1,' cr -in _Cm��r.(_R(°°c�..� OE option.you should NEW RESIDENTIAL PLMB. SQ.FT. T T L:
F" fn hccmne whjml mthe Warkcr.a on''r�agS'Y/Ne huMsr code,you mast
� � fonhwith comply with, provisionsorh Pe be dame]revoked. BUILDINGFEP
[] CONSTRUCTION LENDING AGENCY SHISMICFfif
7 z Iherebyaffirm that there is a construction lending agency for the Performance of ELE IC
U O the work for which this permit is issued(Sec.3097,Civ.C.)
L.mndcrs Name I i
F Leadcr's Address QTY. MECHANICALPERMIT FEE PLUM
O U I cenify That I have marlin,application and s ate that the above information is MF.CHA FEE
correct.I agree to comply with all city and county ordinances andat elaws relating to PERMIT ISSUANCE /l
I" building construction,and hereby amborize representatives of Nis city tomotrupamhe CONSTRUCTION TAX
U move-mentioned Amps"y for inspection purposes. ALTER OR ADD TO MECH.
(We)agrm...save,indmand y and keep harmless the City of Cupeninu against
"Iiabilitics,judgmenss,costs and capenses which may in any way ammo against said City AIR HANDLING UNIT TO 10,M)CFM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10.000 CFM)
' Sinnf APplicent/Cnmrmctor Dam EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNI'1'(10100.000 BTU) Date Receipt#
Will the applicant or future building oce,upant store or handle haourdous material
as defned by the Cupertino Municipal Cade,Cancer 9.12,and NanHEATING UNII'(OVER IW.
e Health
d Safety OOB BTU) TOTAL:
Code.Section 25532p)'1 VENTILATION FAN(SINGLE RESIU)
❑Yes ❑No
Will thcapplicaut or l'mare oildinges:cupans usecquipmcnt ordevices which emit ROILLR-COMP014POR IW,000111U) 15 1�N'�UA
rdaux air contaminants as defined by the Bay Area Air Quality Management BOILER-COMPIOVER 100,00013TU)
FEB 81995
I �is ric:' ❑ NTI
Yes ❑Nn NEW RESIDEAL MECH. SQ.Fp.
I have read the hv,ardnus materials rcquiremc.ts under Chapter 6.95 of IN,
Califomtu Health&Safety Cale.Sections 25505,25533 and 25534. lundersmnd Nat Ur Wrr IyLI
%the building does not currently have a tenant,that it is my responsibility to ramify the
cupwt of the rryuiremenu which must be met prior to issuance of a CeniG<me of
Occupancy.
Owneroroui rired agent Dom 1.. ISSUED BY:
OFFICE
®' 10300 Torre Avenue
• Cupertino, CA 95014
('Mv of
Cupertino ino Building Division
(408)777-3228
(408)777-3333 (fax)
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
--1 have and will maintain a certificate of consent to self insure for worker's compensation,
as provided for
--I have and will maintain workers' compensation, as required by section 3700 of the
Labor Code, for the performance of the work for which this permit issued. My workers'
compensation insurance carrier and policy number are: L/O( ?-?`{
(this section need not he completed if the pcmtit is for$100.00 or less)
I certify that in the performance of the work for which this permit is issued, I shall not
employ any person in any manner so at to become subject to the workers' compensation
provisions of Section 3700 of the Labor Code, I shall forthwith comply with those
,provisions. Date a1-819s Applicant:Q9U10 WAMPL69
by Section 3700 of the Labor Code for the performance of the work for which this permit
is issued.
WARNING FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS
UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES
AND CIVIL FINES UP TO ONE HUNDRED THOUSAND ($100,000.) DOLLARS IN
ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED IN
SECTION 3706 OF THE LABOR CODE, INTEREST AND ATTORNEY'S FEES.
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Design: nn]/ea D.vp no.
nonion,8s In designations This Is an odglnel deign end must Scale:maximum bete 01/03/95
re subled to wrl0cetlon on not ba rebased or copled unless HAMMFS
u aadlusbnent to 9t lob applkeble fee hes been geld or jobamDesigner
oondidwia order placed.
' ciL, ul'
Cupertino
10300 Torre Avenue
Cupertino,CA 95014
Building Division
(408)777-3228
Fax(408)777-3333
December 4, 1995
Resident
10910 Northsky Square
Cupertino, CA 95014
Subject: 10910 Northsky Square, Permit# 27370 - Kitchen Remodel
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 (�
Pnnlaa On R?Cyalod Rwer