25884 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
f CITY OF CUPERTINO HUHA1N(i-PULL tKJLAL PHRIc No.
APPLICATION/PERMIT PLUMBING-MECHANICAL n C Q
BUILDING DIVISION 111111.I)IN(31'ROJEC'I'IDIiNIII+ICA'I'ION G J O
BUILDING ADDRESS: SANITARY NO. APPLICATION SU
BMITTAL DATE:
f� (� Ir UNIT# w 2�xy r
OWNERS NAME: PI10 E: COMRACTOR'S NAML:' .. LIC NO: l `
- buss's N/C CONTROLw
RL TECI'AHNG d. : 1.1 !O ✓�• ADDRESS: ❑
'ONTACP: PHONE: BUILDING PERMIT INFO
A 4HDA S Iq,J QTY. ELECTRIC PERMIT FEE BLDG ELECT PLUMB MHCH
(4S)r?S2-78V PERMITISSUANCE ?C SC
LICFNSEDCONTRACI'OR'S DECLARATION APPLIANCES-RESIDENTIAL. JOH DESCRIPTION
py.Z Ihereby.ffitm that lam licensed underprovisionsof Chapter9(commencing with
uF100 Section 700o)of Division 1 of the Business and Professions Code.and my license is in PANELS
full moutrnd effect.
F$Vy hi[cnse Class Lic.4 UPT02MAMPSftD
tZ,Q L
FON Date Contractor 201-10(y)AMPS
ARCHITECTS DECLARATION - SQ.Fr. AREA � 8/$Q FT.
oz-MOVER IIXXIAMPS _ S
OZ�O IunJerstentl my plans shall be used as public records.
SIGNS ELECTRICAL
V[ `
Qy�y _, Licensed Prefcisional
�.JCCQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
O W U I hereby affirm man I man exempt from the Contractors License Law Por the
W�+QvI—i following reason.(Section7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST. -
�L`N� whichrcyuirexapensduomnsoum..leer,improve.dcumbidi,or repair my structure
prior 1.1t issuunce,almoo,ekestheft,licanlforsuchpermittofileasigne moment POWER DEVICES
aCSO that he is licensed.....aorto the previsions of the Contractors license Law(Chapter
eC 9(commcncing with Section 7000)of Division l of the Business and Professions Code) SWIMMING POOL ELECTRIC �k VALUATION
_y .nkat he Ts exetnp therefm..ndthe basis truth,alleged exempl ion.Any violation of q
OUTLET.-SWITCIi[S-FIXTURES Die
t y`G Section]011.5 by any appl icanl for u Permit subjects the apPlicam m.civil penalty of
$C not more than five hundred dollars($50(y. NEW RI'SIDfiNT1A1.EL[CTR —SQ.Co [II.uvownerofthcW(nprty.ormyemployeen with wagestatheirsolecompensation, STORIHSJ TYPHCONSTRUCDON
y3°0 will do the work.and the structure is oat intended or offered for sale(Sm.904 ,Business
and Prolessions Code:The Connector's Liceme Law does not apply to an owner of
pmPerty whobuildsorimprovex)batten,ondwhnJcessuchwork himselfonhnnghhis
Don
employces,provided that such amprovementsare not itnendedoro(fend for sale.If, OCC.GROUP RLS.UNITS
however,the buildingor improvement is sold within one year of completion,the owner- ��
builAer will b:rve IM1c harden of Proving IM1at he Aid nm build or improve for PurPoa of
❑ Lustwnerosftbepmpeny,am eselusively contracting with licensed contractors to QTY. PLUMBING PERMIT FE1; PLOOD'LONE AEN
construct the project(Sec.7014,Business and Professions Code:)'Ihe Contractors
Licenscl.uwduesnolapply tommwmcrofpropertywbnbuildsotimprovesthereogand PERMIT ISSUANCE
whoemtmetsforsuchpmje iswithacmimclor(s)licensedpununmmthe Contrectoes ALTER FR EA
License Law. ( ) FEE SUMMARY
❑ 1 ate exempt under Sec. .B&P C for Nix racoon BACK FLOW PROTE EV T'SID 0:E5
SANITARY V N
Owner DaleRECEIPT 4
DRAINS-f1.00R,ROOF,ARTA,CON
.WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ihereby.ffirm act lr aveacert ni of ro,docom (Sec.3900,
C.)which FIXTTIRES-PER TRAP RIiCE1Pfw
Wnrkern'C lgrensutinn lnsurmme nrucenilieA copy thereof(Sec.08g1,Lab CJ which PARK PIiE Y N
rose.ell empbyeds under this permit GAS-EA.SYSTEM.I INC.4 0 .ET RI!CEIPI4
PolkBU11.)INCa )IVISION FEES
Compact, GAS-FA.SYSTEM-OVER 4IEA) PIANCIIEC B' 1 IM,
❑ CcoJlfcd copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASEnNUUSTRL WASTE INTERCEPTOR GRA l`
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP <q,Ftr
COMPENSATION INSURANCE
('This section need not be completed ifthe permit is become hundred dollars($100) SEWER-SANITARY-STORM EA.I00IT. ENERGY FEE
or less.)
I certify that in the performance of Me work for which this pemtit is issued.I shall WATER HEATER W/VENT/ELECPR
not employ any parson in any manner so as to became suhject to the Workers' PAID ell
z Contpenmtina Lmesof Calimmia. Data WATER SYS'IEM/IRPATING ism
Applicum NEW R[SIDENII'1AL PLMB. S ,FT.
r 0O NOTICE TO APPLICANT:If,abler making this Cenificam of Exemption,you should V 'TOTAL:
become subject to the Workers Compensation provisions of the ludour Code,you must
Fty. 7 forthwith comply with such provisions or Permit shall be deemed revoked. B LDINGF
UJ (] CONSTRUCTION LENDING AGENCY SEI &10
U z I hereby affirm that there is a construction lending agency for the Performance of
TOTAL: CL C
O the work for which this Permit is issued(Sec.109'1,Civ.C.) i
Lender's Name
F Lender's Address QTY. MSCII IANICAL PERMIT HTP. PLL BIN FEE
V 1 ,my Nat I Aavc read this application it state that the above information is
Fa correct.I agree to comply with all city and corny ordinances and state laws relatingto FERMI TISSUANCE MECHANICAL PEE
building construction•and hereby nuthorire representatives of thiscity to enter upon h° CONS'1RUCTION'I'A
U above-mentioned propcny for inspection purposes. ALTER OR ADD TO MECIi.
(we)agree to save,indemnify and keep hamtless the City of Cupertino against
liubilities•judgmems,costs andexpenses which may in my wayaccmeagainst said City AIRHANDL.INGUND'(TO 10,"CPM)
in consequence of the grnot ing oI hi/s^/B�' t�� Z
HANDLING
Signature oApp>�CctHW
ru� or a .1 E AUST OOD I/DUCT)
f 10,(X10 CFM)
PAID
HAZARDOUS MATERIALS DISCLOSURE HFATING UNIT TO 100,0(10 BTU) Uam Re ipt 4
Will the applicant or future building occupant stoic or handle haiummus material IIEATING UNIT(OVER IOf"BTU) ITH AL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Crile,Section 255120e07
11 Yes ❑Na VENTILATION FAN(SINGLE RISID)
BOILER-COMP(3HP OR 100.0110 BTIJ) ISSUA�N,ICE DATE
Wilhuent,ictmorfuwre building uccepantuseequipmentordevices which emit P' ry '
.wile...contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
isvi r? gpPe a.
❑Yes ❑No NEW RESIDENTIAL MECE. SQ.FI'. "'• !j 1�k taS
I have read the mcardous materials requirements under Chapter 6.95 of the C%/L V 1y94
Otlifomin llenhh&Salmy CnJe,Seaionn 25505,25513 and 255)4. lunderstandthat I/ Vr
if the building d. of currently have a tenant that it is my mspons elity to notify the L�rr
ccup.m of the rcyulremcut,which must be met form issuance of a Certificate of
Oca.pancy.
owner m mllamixm.gent Dae ISSUED By
OFFICE
City of"
Cuperthio
10300 Torre Avenue
Cupertino,CA 95014
Building Division
(408)777-3228
Fax(408)777-3333
December 4, 1995
Resident
22757 Stevens Creek Boulevard
Cupertino, CA 95014
Subject: 22757 Stevens Creek Boulevard, Permit# 25884 - Addition
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 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
PnnfeC r;n Fervc;etl Pacer