27965 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CU P1
BUILDING.-EEECTRIL`AI' PERMIT NO,
APPLICATION/PERMIT PLUMBING-MECHANIC,I.
BUILDING,DI VISION _ BUILDINGPROJKCTIDEN'1'114CATION
I27965
sl11LDING ADDRESS: 3µ(m V-Dn - SANITARY NO. APPLICATION SUBMITTAL DATE
14. UNIT# (//p 1.01'#
OWNERS NAMIi: f, PHONE: CONI RACTOR'S NAME: LIC NO: _
ooC COM! Ol.p
11.
ARCHITECT/ENGINEER: LIC NO: ADDRESS: i, : - ElcaNTnc'1': PHONC: y ELIe.CI'RIC PERMIT FEE OUIL INC PERMIT INFO
��
BLDG ELECTPLU,�fH MECH
PERMIT ISSUANCE ❑ Elter^ ❑
LICENSED CONTRACTOR'S DECLARATION gppLIANCES-RESIDENTIAL TOB DESCRIPTIONpaZ I herehy uffnn that l um licensed under previsions of ChaIlbommencingwilh
00 Section 700(Of Division 3 of fl e Business unit Professions Code.and my license 1.1. ppryPU-g
KUF full force end effect�T— -37160:2-
p
Q U License Cl ss i Lm, 3 1 602• LIP TO 200 AMPS
ZW
vF'i6y
as
't —�— Cnmramor '+LP, 201-IIIf10 AMPS
a-'c,— ARCHITECTS DE'LARATION SQ/F.FOOR AREA $/SQ.IT.
Zorn— OVER 11X10 AMPS
OZ^q Iundcrsmnd my plans shell be usN as public records.
QY � Eirm,ed Ernfesabowl SIGNS IELELTRIGAL
K atU OWNERBUILDERDECLARATION SPECIAL CIRCUIT/MISC.
OaF 1 hereby affirm that I um exempt from the Contractors License Law for rhe
FLL�w following reason "es"
7031.5.Business and Professions Cade:Any city or county TEMP.METER OR POLE INST,
<j wm.n rxrvtres a Permit m ronatmn,inter,amprova eem0han, am awnmr
Y� portni issuance,als�requircsrheepplicam rsuchprmiiiit gmesodermal POWER DEVICES
that lm is licensed pursuant to the, Cmnvucix hew(Chapter
o.yo 9(rontmencing wills Section 7000)0! 'vis'o LR1'1Y-'_'d�Pmfessiov Code) SWIMMING POOL ELECTRIC VALUATION
^rn nr thin he is exempnhertfromand rheb -sf th al Ifxemptimn.Any violation of OUTLETS-SWITCFB35-
�t�a Section 711715 by any apph"m for u pe suhjc is th inppllenm n)ecivil penalty of _ FIXTURES
f 9 0 not more than five hundred doll ).
�F� ❑ I,asowneroO o n o em swithwages avheirwlecompcnsadon. NEW RESIDENTIAL FI.ELTR I
SQJr. STORMS TYPE CONSTRUCTION
m3— will dothc wozon ret In doroffred forma(See.7044,Business
and Rnfcssiore Cot antmnm'a License Lew does not apply t.an owner of
propenywhobuilJaori sNemomandwhoJmsmah work himselforthmugh his
employees,pr widedro such improvements are net mmnd,diamfered Tarsale.If, OCC.GROUP RLS.UNITS
however,the building s improvement is sold within one yemofcompletion,the owner-builder will havethe burden ofproving that he did not build or improve for purpose of -
Wit.).
bits ownerot the prnmy,am exclusively cmntmetingwith licensed,.n.amom ut QTY. ' PLUMBING PEFEE FLOOD ZONE APN
is nsuue,the project(See.7044,Business and professions Code:)The Cmhacmr's
License Lew does not apply he an owner ofpropeny who builds or improves thereon,and PERM]PISSUANCEwho amtme¢forsuch Projects with a c0oacmr(s)licensedpursuant to the Cotractors
License I.aw. AL'1'IER-DRAIN 6 VIENT.WFEB SUMMARY
❑ 1 ant exempt under Sec. ,0&P C fret this reason BACK ROW PROTECT.DEVICE O ' IDE
SANITARY Y_N_
Owner ^ Data RECEIPI'p
WORKMAN COMPENSATION DECLARATION DRAINS-ROOR,ftIXI}s.AREA,GOND. SCHOOL TAX Y_N_
�l hereby affirm that l have a certificate(Camara,rose(-irtma ra certificate of v FI%TURF;S-PER TRAP �J RF.CEIPTp
Workeri Compensation Insurance.ra,e,lifiM copyrhecof(Sa:.3grut.Lab C.)which _7 `1 PARK FEE Y_ry
Polacyplemplo tLrrdet �pesalpgt� GAS-13A.SYSTEM-I INC.40UTLFTS RECEIPT#
•^A / BUILDING DIVISION FEES
C�mpua, GAS-BA,SYS'I'HM-OVIiR 4(EA) PLANCIWCK WEE
LY Cerfi ied copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRI?ASii'I'RAP SOILS INifi
COMPENSATION INSURANCE
(Thin section need not be completed ifthe permit is forms,hundred dollsrs($100) SEWER-SANITARY-STORM EA.200FT, ENERGY IEE
or levsJ
I certify that in the Performance ofihe work for which this permit is issued,I shall WATER HEATER W/VFM/ELECTR
not employ any Person to any manner so as to became subject to the WorkeiPAID
.z Compensation Laws.f Culiromaa. Date ' WATER SYSTIEM/BEATING Date Recein#
Applicant
ZO0 NOTICETO APPLICANT:If,oft,,making this Cenifacateof ExempOom you should NEWRFSIDINT'IALPLMB. SQ.ET. TOTAL:
l� V) become subject to theWorker's Compensation provisions ofthe Lahor Code,you must
� > forthwith comply with such provisions or this pentdt shall be deemed revoked. BUILDING FEE.
pW, z CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm than hero is a construction lending agency for the performance of
U O the work for which this permit is issued(So,3097,Civ.C.) TOTAL: I0 [ELECTRIC FEE
D. P: Lender's Name
O U Lender's Address (Try, MECHANICAL PERMIT FEB PLUMBING PER
1 cenify that I have rod this application and stem that the above information is
const.l agree to comply with ill city and county ordinances andstam laws ralming to PERMIT ISSUANCE MECHANICAL FEE
�^ buildimianarrocti0n,and heresy amhnrize representatives of thiscirymenmr upon the
U2 tim c-memioned property liar inspa:tion pmryses. ALTER OR ADD T'O MECH. CONSTRUCTION TAX
(We)agree to save,indemnify and keep harmless the City of Cupertino agahut
li.bilities,judgmems,costs and expemesvehich mayinenyw.yacerueagaimsasaid Cary AIR HANDLING UNIT(TO ID,000 CFM)
in c.nse,mmee.r the gourna,mod,permit. ,
AIR HANDLING UNIT(OVER 10,"CFM)
Signature of Applicant/Comewor Date EXf1AUST HOOD(W/DUCD 60
PAID
HAZARDOUS MATERIALS DISCLOSURE , HEATING UNIT(TO 100,000 BTU) Dete Receipt
Will the applicant or future building occupant store or handle harardous material �6r
-
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety I[EATING UNIT(OVER 100.000 It IU) TOTAL: �
Code,Section 25532(.)?
❑Yes No VENTILATION PAN(SING LE RFSID)
BOILER-COME(311P OR 100.000 BTU) ISSUANCE DATE -
Willtheapplicamtmfumrebuiirodby uhe Bay eyuipmir ordevac Management
hazardous air contaminants as defined by the Bay Area Air Quuliry Management BOILER 100,000 BTU) PAID
Uisnict? '
❑Yes AN. NEW RIEIDENTIAL MECH.—SQ.PT.
I have read the hmardous maeraals requirements under Chapter 695 of the APR 1 1995
C.lifomi.lieelth&Safety Cade,Secti.ns 25505,25533 end 25534. 1 understand that /r� r 4JG
ifthe building does not currently have a tenant,that it is my ruspoauability t.notify the
occupant of the requirements which must he met prior to issmooe mf a Certificate of VII t�Urttl I INU
Owner or vmhorized agent w Y Dam OF I 4 TOTAL: ISSUED BY: -D
O
City of
Cupertino
10300 Torre Avenue
Cupertino, CA 95014
Building Division
(408)777-3228
Fax(408)777-3333
December 4, 1995
Izumi
21269 Stevens Creek Boulevard
Cupertino, CA 95014
Subject: 21269 Stevens Creek Boulevard, Permit#27965 -Plumbing'
Dear Resident,
According to our records the above mentioned permit has never been fmaled 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 Tone 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.
I
Sincerely,
City of Cupertino
P,wed on Recycled P;lee,