27833 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO - PERMITNO.
BUILDING DIVISION
APPLICATION/PERMIT PLUMBING-MECHANICAL 27833
3 3
7 p BUILUINGPROJECT IDENI'IFICATION L O J J
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBistmALDATE
10 2 l- V� VN� . LUI# "aS
OW 'ER AMID: / E: CO LT R'S LIC NO:
_ U Y NIC CONTROL#
ARCIIITECD`ENGINEF LIC NO: ADDRESS: ❑.
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG PL MECH
PERMIT ISSUANCE ILD
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL qq
OCLD Iherehy aff Divisio h3 ofth Bused undernd Professions
sum mmeneise with r/1 /Iwo � �: IiiYn
F 00_ Section e said of Division 3 of the Business and Pmfessions CWc,and my license is in PANELS \V~r ' -� �[•'�},J�,J
C W full force and affect.
�ZyUj Licenx Class Lic.# UP TO2W AMP$ e
F ti Ilatc Contractor 201-11X111 AMPS S .FLOOR AREA $/SQ.FT.
ZOyZ ARCHITECT'S DECLARATION OVER 1000 AMPS Q
OZ—C) I understand my plaru shall he used as public records.
Ro bb CTRICAL
W SIGNS ELE
6k�„3 Liccnsal Nor c..mal
ZIW< OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
KOQ. I hereby affirm that 1 sm exempt from the Contractor's License Law for the
W'LLy following reuson(Section 703 L5,Business and Pmfessions CoLE de:Any city., may TEMP,METER OR POINST.
F O G wM1ich requires a permit m<onswet,alcor,improve,demolish,or repair any swcturc
"7Y2 prior to its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
m p O that he is licensed pursuant to the provisions of the Character a License Law(Chapter SWIMMING POOL ELECTRIC
o.%o04 9(commencing with Section 70(1 Division 3of the Business and Professions Code) VALUATION
m_y or that he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
,ZP Seeman]0315byany upplisant far a pn
enitsubjects the applicant to a civil penalty of
5S¢O n than five hundred Dollars($5W). NEW RESIDENTIAL ELECfR -SQFT.
CFS sownerofthepmperty,mmycmploy«swi w thcusol eernpensumm. STORIES TYPF,CONSTRUCTION
6'3a Ido the work,and th<stmcmmisnotimend f e6, le Ses.74 ,bliumess
tJPmfessions Cade:The Crntradors Licenx ra n t apply to an owner of
ropcnywholumidsorimprovesmamon,and who < inchwmk hi ughhis
ownemployees,provideJ Chats chimp v notimrn fc�W sale.If, OCC GROUP RES.UNITS
however,the building orimpro e s ye letiTd owner.
M1ale.). will have the bard'^of ensinhd sn�� prove or purpose of T
sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE nPN
❑ Lasownerofthepropeny, lusiv 1 ti g with licensed contracmrs to
antrum the prrjen IS«.]044, ss d fcssions Code)The Conoacmrs
License Lawdoes not apply manownerofpropeny who builds or improves trace,and PERMIT ISSUANCE
whocontracis for such projects with acentuctor(s)licensed pursuantm the Contractor's AL'IEft-DRAIN&VENT-WATER
License law. (EA) FEESUMMARY
❑ I am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FE
t SANITARY Y N
Owner Dare RECEIPT#
• DRAINS-FLOOR.ROOF,AREA,CONU.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ Ihereby'CoupcGntion that Inhave
rance ori cartaofconxnuouf(Secure,or a ttrtibwhiche of Fl%TURES-PER TRAP RECEIPTS
Workers'Cumpen.cation lnsuranceo¢certifiedenpy thermflS«.38W,Lab C.)which PARK FEE YN
covers all employee's under this permit. GAS-LA.SYSTEM-]INC.4 0UTLE'I:S RECEIPT#
Policy# BUILDING DIVISION L--S
Company GAS-EA.SYSTEM-OVER4 MA) PLANCHECK FEE S
❑ Certified copy is hereby.famished.
❑ Ceniliedcopylsfilcd with diedtyinepectiondivlsion GRE ASMNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS GREA$ETRAP SOILS FEE
COMPENSATION INSURANCE
(Thisscctionneed not bemmpleted ifthe permit is for one hundreddollars($IW) SEWER-SANITARY-STORM EA,200FT. ENERGY FEE
or less.)
I certify that in the performance of she work for which this permit is issued,i shall WATER HEATER W/VINT/ELECTR
not employ any person in any manner so as to become subject to the Workers' PAID
Cmmpenmtinnlawsof Callfomla. Duo WATER SYSTEM/TREATING Date Receipt#
7-. Applicant
Z O NOTICE I'O APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLM B. SQ,FT. TOTAL:
^ become subject o the Workers Compensaum provisions ofth.labor Code,you must
� , forthwith comply with such provisions or this permit shall ba dccmW revoked. BUILDING FEE
00.. (] CONSTRUCTION LENDING AGENCY SEISMIC FEET
I hereby affirm the there is a construction lending agency for the perfortnanu of
UO the wr
ork for which this permit is issued(See 3M7.Ci,C.) T L: IiLECIRICFEL
lender's Name
0Lenders Address QTY. MECHANICALPERMIT FEIi PLUMBING FEE
U I unify that 1 have read this application and sura that the above miff m tans is MECHANICAL FEE
�•" W correct. lag,«to comply with all city and county ordinances end stain Iowa relating to PERMIT ISSUANCE
huildingmnauuctlon,md herebyuutbmize represenmtivesufthia city 1. upon the
U ,Z CONSTRUCTION TAX
uMve-mcntagree property for insp«tion keep has. AMER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City cu a Cupertino against
.. Iiabi'ntsequen cmrrreMMMnq���ctttorrrsutanB expenseso �wh';ch ttuyinany wry aumeagaiaa svd City AIR HANDLING UNIT(TO Eight)CFM)
in
AIR HANDLING UNIT(OVER 10,010 CFM)
Si more of A`pplicanip"mmuaor Data 'J EXHAUST HOOD(W/DUCq PAID
HA/-ARDOUS M E IALS UISCLOSIIRF.
HEATING UNIT(TO IW.t10p RTU) Dale Receipt
Will the applicant or future buildi Tenpin,stere or handle herardous material HEATING UNIT IOVBft IW.fN10 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Seai Yes ❑No
x)1
El VENTILATION FAN(SINGLE RFSID)
❑Yes
BOILER-COMP(3HPOR IW,tNXI BTU) /Ty �IS�SUANCE DATE
Will she a cortarnom insursure defined by the Bae expuArea ern Quality
Management 9
. harardou.a air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER I W.000 BTU) ^
Diso-ictl pn
❑Yes 11 No NEW RESIDENTIALMECII. SQ.19. `�/��.L 19n
1 have mad the haeardous materials requirements under Chapter 6.95 of the VV
California Ilcalth&Safety Code,Sections 25505,25533 and 25534. 1 understand that 2
if the building mes not currently have n tena.i.that it is my aspundbility to notify the G
occupant of the requirements which must be met prior to issuance of a Certificate of
Occupancy.
Owner or^nlamired agent Dam ISSUED BY'
OFFICE
CILC- of -
cupeTth10
10300 Torre Avenue
Cupertino,CA 95014
Building Division
(408)777-3228
Fax(408)777-3333
November 29, 1995
Resident .
108%2 Leavesley Place
Cupertino, CA 95014
Subject: 1042 Leavesley Place, Permit 9 27833 - Bath Remodel (2)
Dear Resident,
• �.
)1 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 youf 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
P inmd on Pecvdvd Paper