28411 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO N ILDI G-ELBC`I'RICAL PERM]"I'NO.
BUILDING.DIVISION APPLICATION/PERMIT PLUMB N;-MECHANICAL p p �q
RUILDIN'GPROJECI'IBRNI']F'ICA'I'ION 28411 O 4 1
UILDINGG A�DD•RREESSSS� DA //w��/^//�///ssv f///���� # SANITARY NO. APPLICATION SUBMITTAL DATE;
2-v LV 0 I ' • ( � 1Nir LO1# V ��P- S
OWNS S 0 err �F� RACfQp$�a�glf
`Y ry 3//rc` C COM1/IB�OLM
ARCI]ITELT/LNGINEI:R: LIC NO: ADDRESS:
CON'T'ACT: PHONE: /`'• �J BUILDING PERMIT INFO
QTY. ELECTRIC PEiRMIT FEE
BLOC ELECT PLUMB MECH
t PF,RMITISSUANCE �t ❑ ❑
LICENSED CON'TRACTOR'S DECLARATION APPLIANCES-RESIDENIIAL
C=Z Iheebyaffirmthatlam licensed underprovisionsof Chpt
eer9(cotnmencingwith JOBDESCRIPTION
LwOO Senion 90(111)of Divisinn 3 of the Business it Itofcs,ime,Code,and my license is in PANELS
wC LQ aV full foce unit effect
Clas Llc.a
1�T02INAMFS
AVID—
Data
GECTS Dr 201-IBRO AM1YS
F ,o- ARCHITECT'S DECLARATION SQ.FT.BOOR AREA $/SQ.tT.
ZOos— I understand mypa.,,loll he axed.publicomoMs. OVER IOOIIAMP$
OG C F
FrnFW SIGNS ELECTRICAL l.to Wm Q(2 3
Q F•j Licensed Profesional vv W
��a'Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
x'04uo I hereby nmfion.(Se thin 1 am exempt from 0e Contractor's e,Any Law for the
m3ay which,epi so n.(Section 9031.5,flintiness and improve,
Co de:Any city or county TEMP.METER OR POLE INST.
which inquires a permit to con,tma,elm,,impnwe,demolish,or rtpoig any stmaurt
pit lolxismence,alvs mquitestheapplicnntforsuchpermino fileasined statement POWER DEVICES
� Lao than he in licensed panaam m'he prnvivions of the Contractor's Licennc Law(Chapler
aa�z 9(commencing with Section 7080)of Division 3 of the Business and Protbssious Code) SWIMMING IY)OL CLEC'I'RIC VALUATION
qtr- othat he is exemptb,mfrom and the bssis(m the elle (on.An ed exemption. f
Amyr a
g piyvto1a1ianm OVIL1SrS-SWITCHES-FIXTURES
�ZQ Poancreion than can...Enapplicant r,(150tmit subjects the upplicanttoacivil Penalty of
W—.¢ nal mare than live hundrW Jallac($5 W).
NEW RCSIDF.NI'IAL LLIiCfR SQ.IT. STORIES TYPE CONSIAUCf10N
_o ❑ I,asmwncroftheproperty,ormycmplmyeeswith wages ustheirsolccompcnsution.
SB= will dm0ewors and the Me m aisnot i,Lima or awdosfmnab(Se,.an Business
unit Professions Comorinpr Contmaor. ndwho
Law hoes not apply m an owner of
,ownpunenywhn s,numinflana nlhemnn,nndarts.as intended
ntendch k himsocedfiifform nmgh his OCC.GROUP RES.UNITS
employees,he en,provided iponvahimprovmmwithin notintendednraffcsedforsale.I-
howevegtheavet a burimprovementinsoldwithinoneyear or impairs,fo,theowner- T
hale.). will have the burden of proving thin he did not build or improve for purpnu of
n:ded' QTY. PLUMBING PERMIT' FEE n,OOD ZONE APN
❑ Las owner offfic project(Sec.
usinsivelycorofessionng with ice)ed The Coranmsm
oceans the-spot(Sec.1614,Business and Professions Cale:)The marm.,mrs
License Lawdoar such
pplyro with a crmfpmpeny whnsed puorimprovca Conlon,and PERMIT ISSUANCE
lwho conancisice,.Law.lar such pmjecls with u cantrnaur(e)licensed pursuant to the Cnmrucmr's
lJcense Lew. ALI'IiR-DRAIN&VENT-WATER(13A) FEE SUMMARY
❑ 1 am exempt under Sec. .B&P C for this reawn OUTSIDE FEES
BACK FLOW PROTECT.DEVICE SANITARY YN
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. BE E1PTp
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ I hereby affirm that l have a certificate ofmawrit to self-issue,or a reniiate of FIXTURES-PER TRAP RECEIP`p#
Workers'Compensation Insurance or a candied copy thercof(Sm.3801,Lab C.)which PARK FEE Y N
covers all employee's under this permit. GAS-HA.SYSTEM-1 X'
S — RECCIPTIt
Policy N .F.� BUILDING DIVISION FEES
Company GAS-FA.SYSTEM-01M4(EA) V NCI IECK FEE
❑ Certified copy Is hcmhy famished.
❑ Certified copy is pled with the city inspection division. GREASUINDUSTRL WAS'I IN'I'IiRC1iYfOR AU GF'EE,
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP ti,
ILS FEE
COMPENSATION INSURANCE
(ThlssecJon need not be completed ifOtc permit is forms,hundred dollars($100) SEWER-SANITARY-S'1'ORM EA.YO(IFI'. P ERGV FE.
o less.)
I certify the path, morrommof maser cwork astor which this Permit is issued,Ishallkers' WAITJt HEATEItWNF:NI'/ELECIR
not employ any person 1i any manner. as to bammc subject m the Waders
Compenautinn lows nl Celifomie. Dine WA'1'CR SYS'IfM(rRFA'1'ING Dam Receipt
O z Applicant
z NOTICE TO APPLICANT:If.a(te,makingth]s Cenifcaemf Exemption,you should NEW RESIDENTIAL PLMB. SQ.II' TOTAL:
I) beemme,ubjecuo the Worker's Compa-anon provision,ofine Lahor Code,you must
a � forthwith comply with such provisions or this permit shall be dammed revoked. B ",5w, /e
4 (� CONSTRUCTION LENDING AGENCY ISMI
I hereby affirm thunhere Is n construction lending agency for the performance of
U O TOTAL: :.,,M RIC FF,e
the work for which this permit is issued(Sec.3099.Civ.CJ
lender's Name PLUMBING FEE F lender's Address QTY. MECHANICAL PERMIT PEE
U 1 empty that 1 have tend Otis uppliwtinn and stat,that Na abuse infomustinn is
>" W coned. PERMIT ISSUANCE lugrte uwomply with all city and seamy ordinances and stem laws relating la MECHANICAL FEE
I^ n' building conswction.and hercth,malodm repinuntativesofthiscuy to a ,upon the
VI CONSTRUCTION TAX
U Z insane-mentioned property tori pemion pumoses ALTER OR ADD TO MECH.
(We)agree to save,ind nil'y unit keep Tcs Mc City or pcnino against
Iiabilities.judgmen0,costa expcnus whic yin any way ac eugainn sail City AIR HANDLING UNIT(TO l0,WU CFM)
407
incon e u, gof thisex,mpc
20 e7 Inde�: AIR HANDLING UNIT(OVER 10,0(10 CFM)
SignazurqEdf ApplicanVConvncmr Data EXIIAUSTHOODWDUCq PAID
I IAZARDO ' AATERIAL. ISCLOSURE HEATING UNIT(TO 100,1100 BTU) Data Receipt#
Will the applicant or tum wilding scup Ismrc or handle haesrdon......coal HEATING UNIt'(OV13R Ilq.000 BTU) IOTA I-:
as de0n rl by the Cupenino Municipal CNe.Chaprer 9.12,and pie Health end Safety
Code.Seednn 25532nd? VENTILATION FAN(SINGLE RESID)
❑Ycx ❑NO
ISSUANCE DATE
Will the applicant or future buildingumupsent useequipmemordeviceswhich emit BOILER-COMP(3HP OR 100,000 BTU) py
Ieurdoun air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100.010 BTU) 1— O
stria?
❑Yes 0N NEW RESIDEN I'IAL MECIL SQ.FT. JU � �
I have mad the Inventions materials requirements under Chapter 6.95 of the /s v(�` RYI
Califomin I Icalth&Safety Code,Section,25505,25533 and 25534. 1 understand that C/(
if the building dues not currently have a Puna,that it is my responsibility In notify the r yr sur
mon,sent of the inquiremems which must he met prior to issuance of a Certificate of tK y/q
Occupancy. IZZ170 .��`�
Owner m autharimd agent Dam TOTAL: ISSUED BY: ��///FX/�a{'/�I
OFFICE
• 10300 Torre Avenue
O. Citv
Cupertino, CA 95014
of,
Cupei tufo Building Division
(408)777-3228
(408)777-3333 (fax)
April 23, 1996
Resident
20260 Pacifica Drive
Cupertino, CA 95014
Re: Expired permit (copy attached)
Dear Resident:
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
Punleo on Recyclod Paper