27950 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF-CUPERTINO BUILDING IA; RICA PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING..MECHANICAL 27950
BUILDING PROJH[T IDENTIFICATION
BUILDING SANITARY NO. APPL�TX [SU� TAh DATE
UNIT# LOT It b
OPHONE: CONT CTOR'S NAME: LIC NO:
3 NA: CONTROL.#
LIC NO: ADDRESS: ❑
NTACT: P ONL;
QQ qqWP QTY; ELECTRIC PP.RMI9' ' •FEE BUILDING PERMIT INFO
HIM ELECT PLUMB MUCH
PERMIT ISSUANCE ❑ F-1 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RFSIDENITIAL LOB 015CR11'1'ION
nmz I hereby affirm that l am licensed under provisions of Chapter 9(commencing with
ta100 Sconce 7000)of Division 3 of IM1e Business and Professions Code,and my license is in PANELS
,y full force nod efJpc 9
QVz license IUde '�W Lic.#J4�
DUP TO]Of1AMPS
ti6y are ContractorL201-101X1 AMPS
Fy2, A Cll Ise
DECLARATION SQ'IrI;F7gOR ARG E/SQ.III'.
Z O w— OVER 10(10 AMPS ,{/��\\\
OZ-0 lunderemnd.,,Inns shall be used as public records.
y t:{�i SIGNS Ii1.ECTRICAI,
Q EJ Licensed Prnfexsi...I
L,�V OWNER-BUILDER DECLARATION SPECIAL CMCUI'f/MISC.
O a I hereby affirm Iba I am exempt from the Contractor's License Law for the
3LLyQ following ounce.(Seed.703L5,Business and Professions Coda:Anych,ine unty TEMP.M=-R OR POLE INST.
f5m.] which requires a permit to construct,al¢q improve,demolish,or repair any structure
Cw}nto its ismunce,alsore aloes thea licant restrict uo file.signed statement POWER DEVICES
prim 9 PP permit gn
W C<C) Lha he is licensed pursunnnn the provisions of the Contm iae's License law(Chapter
n p,o1' 9(cam he is exempthBrefrom 000)of Division 3nlthe ed exemption.
end Professions Code) SWIMMING POOL ELECBIC VALUATION
iW—rn
or l)am he is exempt therefrom and the basisfor the allege)enemPlion.Any violation of OUTLETS-SWITCHES-FIXTURPS \
< Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
yy
announce than Bva hundred dollars($500).
W5� ❑ I,asnwncofthe t NEWRESIDENTIALELECfR _SQ.FT. STORIES 'TYPE CONSTRUCTION
6 proper y,ormy employeeswith wagesastheir mecompensdion,
a willdothe wnrk,eadtbesuucwrs is not inumdedoroffered finaale(Sec.]044,Business
and Professions Code:The Gmtrmter's License Law does not apply to an owner of
property whobuilds or improves thereon,and whodoessuch work himselfor through his OCC.GROUP RLS.UNITS
own employees•provided that auromre
chimpveeulanot inteadetwoEerel Barrette.If.
however,the huildingor improvement is sold within one year ofcnmpletion,dwowner- TOTAL:
builder will have the burden of proving that he did am build or improve for purpose of
sale.).
❑ I,as owncrofthe property,amexclusively contracting with licensul contractural to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct[lie project(Sm.7044,Business and Professions Cole:)The Contractor's PERMIT ISSUANCE
License Law does nor apply to an owner of property who builds,or improves thereon,and
who contracts for such projects with aoontmelia(s)licensed pursuant to the Contractor's
License Law. ALTER (EA)) FEE SUMMARY
❑ I em exempt ander Se<. ,B&P C for this reason BACK FLOW PROTECT.DEVICE
SANITARY OXY A N
Owner Date RECEIPT p
/ DRAINS-FLOOR,ROOF,ARIL ND
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN_
❑ Ihembyufrirmtlallhaveacertifcuteoreonsenn^,self-inmm,nracenifi ateof RECEIPT#
mkerCCompersatinn lnsumnceoraceniBed copy thercaf(Seo.J800,Isb C.)whi<h FIXJURPS-PER'fRAP PARK FEE Y N
Policrssll cmplgyge ndyr 's t GAS-EA.SYSTEM-1 INC.40UTLEIS RECEIPT#
y#�u—G�/7 / 09—��✓ BUILDING DIVISION FEES
ComponyJa.aJ/�Q /0 gQ�/- GAS-EA.SYSTEM OVER 4(EA) PLANCHECK FEF.
❑ Certified copy is hereby famished.
❑ Cenifi<d copy is fled with the city inspection division. GREASE/INDUSTR,WASTE INTERCEPTOR GRADING ITE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASF,TRAP SOILS FEE
COMPENSATION INSURANCE
(This section resistant be completed ifthe penail is for one hundred dnliers(SIM) SEWER-SANITARY-STURM PA.200FT. ENERGY FEE
or less.)
Icmid,(hatin do,perfnrraiment the work for whielOhi.permil is issued,l shall WATER I IHATER WHENN UELECTR
not employ any person in any m as to become subject to the Workers' PAID
Compensation Laws of Califomia. Date so WATER SYSTEMI REATING Date Receipt It
Q z Appraisal -
z 0 NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIl. SQ.FI'. TOTAL:
I-+ rq become subject o the Worker's Compensation provisions of the labor Code,you must
•" t"" forthwith comply wi fit such provisions or this permit shall be deemed revoked. BUILDING I7I3H
W25 CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm that there is a construction lending agency for the performance of TOTAL: ELECTRIC PER
O Ne work far which this permit is issued(Set.304/,Civ.C.)
rr Lwder's Name
0 L Lender's Addrass QTY. -: MECI IANICAL PERMIT' - 'FEE . PLUMBING FF,B 3 0
V I certify that 1 have read this application and state that the above information is
correct.l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE9 — MSCI IANICAL FEE
rn building construction,and hereby autitorizerepresentatives ofthis city to enter upon the `/ CONSTRUCJ'ION TAX
U Z shave-mentioned property for inspection purposes. ALTERORADDTOMECTI.
(We)agree to save,indemnify and keep hnnNcas the City of Cupertino against
liahi li ties,judgment,costs and expenses which may in any way accrue against said City AIR HANDLING UN IT(TO 10.001 CFM)
in caruequence of the granting of this permit
ATR HANDLING UNIT(OVER 10,000 CFM)
Signature of ApplicanVConuector Date "HAUS THOOD(W/DUCD PAID
IIAZARDOUSMATERIALSDISCLOSURE I WAI'INC,UNIT(TO 100,000 BTU) Data Ro<eipl#
Willthe applicant or future building oocposenue,ter handle hazardous matened HEATING UNIT(OVER 100,00,71 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Crede,Session 25532(u)^
El Yes ❑No VFWILA ZION PAN(SINGLE RPSID)
Willmess air
faPPmmu of as building by the
A iPmir unlit Management
/ BOILER-COMP(311P OR 100,011(1 BTU) /� — ISSUANCE DATE
comanminants m Defined by the Bay Arca Ar Quality Mmagemrnt
BOILER-COMP(OVER 100,000 BTU)
Dlstrlct+
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have red the hazardous ran teiala reluilexacm,under Chapter 6,95 of the
California Health&Safely Coda,Sections 25505,25533 and 25534. I understand that
if the building does not currently have a terant that it is my responsibility to notify the
t of thn rcquir• eats which must be met prior to issuance of.Cenifi<ac of I t
cy
u n e ago[ Date TOTAL: ISSUED V�
OFFICE G�-�
^ ^ r t r
HALZW'
:y�
r.® I
? 10300 Torre Avenue
of Cupertino,CA 95014
tupertino Building Division
(408)777-3228
(408)777-3333 (fax)
June 18, 1997
Homeowner
21940 Rucker Drive
Cupertino, CA 95014
SUBJECT Permit#27950
Dear Homeowner:
We have been going through our files in the Building Department, and contacting those
people with permits remaining"open.
• According to our inspection records, the subject permit has not had a final inspection.
Many times an inspector will sign the permit in the field, but overlook reporting all of the
information to the clerical staff for input into the computer. If this is the situation and
your permit card shows the final sign-off,would you please contact us so we may
complete our computer records? If the permit is not signed off, please call to schedule an
inspection for final closure of the permit.
Because of the large volume of paperwork within the building department, we cannot
separately monitor the progress of each permit. We ask that you give this notification
your immediate attention. If we do not hear from you within ten (10) working days, we
will dispose of the file and remove the records from our computer.
Thank you for your assistance.
Sincerely,
CITY OF CUPERTINO
Christy Akatiff, Administrative Clerk
Parfea on RegGee Paper