27929 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUILDINU A PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
27929
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
I�LIILDING ADDRESS: SANITARYNO. APPLICATION SUBMITTAL DATE
UNIT# LOT#
NAME P ^ TR ORTS�i ': IC NO:
ata / NIC CONTROL#
%RCHITECT/ENGINE' LIC NO:
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE 0 ❑ ❑ 1 K
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL �I�
M=z I hereby abltm that l am licensed underprovisions of Chaptcr9(commeneingwim )OB DESCRIPTION
0.100 Section 7000)of Division 3 of the Business and Professions Code,and my license is in PANELS
<W, mu force and clrecL - /� _�, ^,-_ _ �s
Fzty License Class Li<.b UPT0200AMP5 a1r"/v'S p,Jl�}s.,y�'
F ti Date Common, 201-1000 AMPS S FI'.FLOOR AREA $)SQ.FT.
z0yy ARC]I ITF,CT*S DECLARATION OVER 1000 AMPS Q -
OZ—'0 I understand my plans shall la,used as public records. -
F.,`FIL SIGNS ELECTRICAL
Licensed Professictual
aced'6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KOa V 1 hereby affimt that 1:mt exempt from the Connector's License law for the
W 3 a y following reason.(Section 7031.5.Business and Professions Code:Any city or county TEMP.MUTER OR POLE INST.
F u'O e. which ex,foes a permit ea construct,once.improve,demolish,or repair any structure
,WW 2 to its issuance,da.rc thea licam for such u.fileasi dstamment POWER DEVICES
prior yuires PP pend gnc
yC a C that he is licensed pursuant to the provisions of the Contractors License law(Chapter
o.Xoy 9(commencing with Section]000)of Division 3 free Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
0.- or that he is exemptherefrom and th basisfarth lle elexem u An 1 u f
�_rna g p'on. yvi.a'.n. OUTLETS-SWITCHES-FIXTURES
F Z Q Section 7031.5 by anyhu applicant for it u the aPPlic 1 pevly of
xSC not mnrethanfive hunJmddollars e n NEW RESIDEMIALELECTR _SQ.FT. STORIES, TYPECONSTRUCIION
a3e—` ❑ I.asownero(thepropeny, y p gees aayXevs Ie mpensedon,
willJmhe work, tithes e - i end t e orsale(S J044,Business
and Professions de of s lie n ties not apply to as owner of
pr.pcny wh ui r proves t�e�dw s such work himself.,through his OCC GROUP RES.UNITS
n employees, r or
dcd that,a emernsicenotimendederoffetcadfrrsale.If,
howeveq thcbuildit improve old withinone yearofcompletion,thc.wner- TOTAL:
builder wad haveth oadan ofproving that hedid not build orimprove forpurpose of
sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE AIN
❑ 1.as the pr ofthject property4,Business
andly Profeting ssions
Code)th One
Comaoloto to
onswn the project(Sec.to an
Business and ywholauld Code)The Contractor's
License Law Jocsnnt apply num ownerol pr.pcny wM1obuilds.,improves Chereon,and PERMIT ISSUANCE
who contracts forsuch project,with acmmrinctn(s)licensed pursuant to the Conoaetor's
License Law. AI:f13R-DRAIN&VENT-WATF,R(EA) FEE SUMMARY
❑ I nm exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUISI DF PEES
SANITARY Y N
Owner Dare RF.CEIPI'#
WORKMAN COMPGNDRAIN$-FLOOR,ROOF,AREA,COND.SATIONDECLARATION SCHOOLTAX Y N
❑ Thereby affirm thmlhave vicenifenm of consenuo self-insure,orecenificate of RECEIPT#
FIXTURES-PER TRAP
Worken'Compensminn lnsumnce ure<mified copy mereof(Sec.3500,Lab C.)which PARK FEE YN
covers all employee's under this fiction. GAS-GA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy X BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVEB 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Combed copy is Bled with tpe city inspection division. GREASEBNDUSTRL WASTE INTERCEPTOR GRADING WE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This aretion need not Ise completed ifthe permit is forone hundred dollars($100) SEWER-SANITARY-STORM EA.2WFT. ENERGY FEE
of less.)
I cenifythm in the do...of the weak for which this pe man is issued,I shall WATER HEATER W/VENT/ELECIR
not employ any person in any m as to become subject m the Workers' PAID
z Compensationlawsnf Ca]ifom]a. Date so WATER SYSS'GM/TREATING Date Receipt#
Applicant
Z NOTICE TO APPLICANT:If.afar making this Cenlfican,of Exemption,you should NEW RESI DENTIAL PLMB. SQ,FT. TOTAL:
(q become subject o the Worker's Compensation provisions of the Labor Code,you must
H fonhwili comply with such Provisions or this Permit shall be,deemed revoked. BUILDING FEE
C4
_
W Q CONSTRUCTION LENDING AGENCY SEISMIC FTI?
I hereby affirthat there is construction lending agency for me perfaomnnce of
U O affirm that
the work for which this permit is issued(Sec.3097,Civ,C.) TOTAL: ELECTRIC FEE
bonders Name
W F Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
V 1 certify that I have mad this application and state that the above information is MECHANICAL PGE
correct. l agree to comply with all city and county ordinances and site laws relating to PERMIT ISSUANCE.
I"-' Q. bolldingcmntruction,and herehynummme represcnmtives offlar,tymemmrupomtr,
CONSTRUCTION TAX
L.) ,Z aMv(We)agree property for mnify on lace
Torr ALTER OR ADD TO MECH.
(We)agree a xsve,indemnify kcc harmless y City of Cupertino against
is liabilif .judgments,costs and"'pen. wM1i mayinanyw yacerve against said City AIR HANDLING UNIT(TO IO,tXp CFM)
enee of the granting of rots pe
AIR HANDLING UNIT(OVER 10,000 CFM)
igna re
IV
Da¢ EXHAUST HOOD(W/DUC I PAID
HA9A US MATFRIAIS DISCLOSURL
HEATING UNIT(TO IW.tXIp BTU) Data Receipt#
Will the applicant or fu re building occupant store or handle hazarA.us material
as defined by the Cupertino Municipal Code.Chapter 9.12,and me Heald and Safety I HEATING UNIT(OVER 100,000 BTU) gg�kk pp TOTAL:
Cede,Senium 25532(x)? VENTILATION PAN(SINGLE RESID) r N Y D
13 Yes ❑No
ISSUANCE DATE
Will the applicamorfmurchuddingeccupant use Wuipmentordeviceswhdchemit BOILER-COMP(JI{P OR IW,IMq BTU) ��� ��
hazardous air contaminants as defined by the Bay Area Air Quality Management BOIL17R-COMP(OVER 100,000 BTU) . 1995
SDIsWn?
❑Ycs ❑No NEW RIiSIDGNTIAI.M[C1I. SQ.FT.
CITY OF UUFEHTINO
1 have read he hat Lely Cott,conferrals 5505.25 33 under 34.1 runaround
ti o of the
California,buar,du, ut coo Calle.acetone$. bar
,25533 and 25534.1 umdc mend that /(�//jam/
ifthebuildingenonoteurcmtlyhave amount,thmttrmy rerraceof. ter nmity the 'T
occupant of the rcyuirements which mit be met prior m issuance of n Certificate of _
Occupancy.
Owner or aumoriuJ.gcm Dam L. ISSUED BY:
OFFICE
M .
MV
®' 10300 Torre Avenue
Cupertino, CA 95014
('.ilc of
up CA x,111.0 Building Division
1 (408)777-3228
(408)777-3333 (rax)
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
--I 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 issuey rkers'
compensation insurance carrier and policy number are:
(diis section need not be completed if the pmnil 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
with th
provisions of Section 370 of the Labor Code, I shall forthwith com e
provisions. Date / P'S�Applicant:
by Section 3700 of the Labor Code for the performan e of th 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.
•
Prinfcd on IfocWYud!'apm
1 .0- C of,
Cupertino
10300 Torre Avenue
Cupertino,CA 95014
Building Division
(408)777-3228
Fax(408)777-3333
November 29, 1995
Resident
22588 Lazy Oak
Cupertino, CA 95014
Subject: 22588 Lazy Oak, Permit# 27929 - Furnace
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. n
Sincerely, )L
City of Cupertino ,( �
•
Pnnred on Recycled Paper