23589 APPLICANT TO FILL IN INFORM4TION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proea Identification PERMIT NO.
Building Address: • .P /� ^C Q
Z0 L0 2' RAo"-kWlL- 'r .. G VS J o
wnerearrc: one: _ p
LQNq (i-GYL-�$ N-. O . It. CITY OF CUPERTINO-BUILDING DIVISION I �����
C n terror Name: ( '// LI¢.Na APPLICATION I PERMIT �L
Wk-Lb .JU 0^/ Ty I BUILDIJCa] TRICAL-PLUMBINCMECFIANICAL CATECARY CONTROL«
rchitect/Engineer Lic.N.
.QT9 ELECTRIC PERMIT, • FEE BUILDING PERMIT INFO
Address: PERMIT ISSUANCE ❑ ❑ Il$ O
LICENSED CONTRACTOR'S DECLARATION LTIO
I hereby
ivi.im3afthe usir laions nd Pmfnsimsr9(mnunmc APPLIANCESRE9DENTIAL ]OB D[SCRQ'170N
lnense11.ftfl 7000)ofd(effect. afthe Buelnnsand PseteselonsCode,and my •�,0,
license lslnfull and effect. PANELS
License by I!I& Co.« 3 d'
Date Conlnctrr `
ARCHITECTS&ELARATION 201-IODDAMPS
fl7 lunderetand my plans slug be orad apubllcremrdw OVERICNAMPS L OOR $/SQ.Fr.
6 Licensed ProfeaQanal SIGNS ELECTR CAL A e
�j Lu OWNER-BUILDER DECLARATION P l ) T E R
rn `U7 SPECIAL CIRCUIT/MISC /T
Zt, owing rasRrmthatlam31.5,B from the d Pmfiesdons ode:ense Law for the
pp following reason.(Section 7031.5,Business and Pmfevlona Code:Any city or �S Z
O Z i. TEMP.ME'1'IA OR POLE INST. C 7/5 G
P� rountywhlch requ4eaa perNtroronstruct,alter,lmpmve,demoi6h,or repair V
any structure prior to its Issuance,also requires the applicant for such permit to POWER DEVICESATE
Re a signed statement that he is licensed pursuant to the provisions of the
Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
Ell
alon3 ofthe Buslnessand ProfemionsCode)orthat he is exempttherefromand VALUATION
0 the basis for the alleged exemption. Any violation.of Section 7031.5 by any OUTLETS-SWITCHES-FIXTURES
applicant fora permit subjects the applicant to a civil penalty of not more than
$
five 1,as
ownerdollarof
hepr(SM. NEW RESIDENTIAL ELECTR SQ.FT, STORIES TYPE CONSTRUCTION
I,as ownerli theproperty,ormy employees Is not Intended sawithwages r thele sole
�7a compensation,Bu.010theworkfessor and stmcte:TheCntractro License
eLaw
❑ d for
sae(Sec. ppy to alnowandfproperty Code:The Contractors License Law
3$ does not apply torn owner of property who nIIds or mploimproveted that such
OCC.GROUP RES.UNITS
whodoes ntsach nrffite dedorwghhisownle.lfh weprtheb ildingch -
ImprovementiarcnotIntended earo(cdroesole.If,howweg deer ill have TOTAL:
Improvement bwld within one ycarofcompictloq the ownerbuild.Twill have
ft-urden of proving that he did not build or impmve for purpose of sale.. QTY. PLUMBING PERMIT FEE
u L as owner of the property, FIAOD TONE MN
p party,am.x014,Busl contracting with licensed PERMIT ISSUANCE
contractortoro Licentheproject(Sec 7014,Btonem and of pro ons Cade:
The Contractor's License Law does not apply to an owner of property a ALTER-DRAIN Yc VENT-WATER(EA)
Wilds or Improves thereon, and who contracts !w such pCajern with tis a
c,,➢.ttj.Iactor(.)licensed pursuant to the Contractors License Law. BAIX FLOW PROTECT.DEVICE �s FEE SUMMARY
IJ 1 am exempt under Sm B 4 P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RFCF]I'I'«
_.WORKMAN COMPENSATION DECLARATION FIXTURES-PER TRAP SCHOOL TAX Y N
Ei hereby affirm that I have o lreura to of current to self-husirs,reof ora RECEIPT«
certificate ofWorkere Compensationlnsuranre oracertified copy thereof(Sec. CAS EA.SYSTEM-]INCA OUTLETS PARK FEE Y— N
Policy
Isis C.)
I'oliry Y CAS EA.SYSTEM-OVER 6(EA) RECEIPT«
Cam any BUILDING DI VISION FEES
copy is herebyth the cid. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECICFEE
Certified copy V filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREA5ETRAP PAID
COMPENSATION INSURANCE SEWER.SANITARY-STORM EA 200FT' Date Recei t#
(This session need not be completed lithe permit V forons hundred dollars
(s100)arlen3 WATER HEATLRW/VENT/ELECTR ENERGYFEE Y N
1llnot that emIn ploy
an person
any annex work foras to b ca eermR is Ito theed, —
I shall not employ any person In any manner n u to become object to the
Workcre'Compensatiowsn lsof California. ATER SYSTEM/
la. Date TREATING PAID
O Z NOTIAppliCnt NEW RESIDENTIAL PLMB. SQ.Ff. Date Recei t#
Z O NOTICETOAPPLICAM:1L making ompe Certificate of Ex¢mpolon,you
� rn .hwldWrome subject to the Workers Compensation provisions of the Labor TOTAL:
Code,you moat forthwith comply withsuch prov6lons orthis permit shall be BUILDING FEE
W j deemed revoked.
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby afBrmthat thereb e construction lending agency for the perform ELECTRIC FEE
Z ance ofthe work forwhlchlhls permit is Issued(Sec.3097,Civ.C.) T awe
U O Lender.Name PLUMBING FEE
LL F Lender.Addmns QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icar fythatl have read thi.appllcationand siatethatthe above Information
C romcl.Iagree to comply with all city and county ordinances and nate law. PERMIT ISSUANCE FEES PAID:
} relating tobullding construction,and herebyauthorIm representatives ofthls
N
(_ V) city to enter upon the above�mentioned property for inspection purposes. ALTER OR ADD TO MECH.
_ (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Recei t#
against liabilities,ju dgments,costs and expenses which may In any way aceme AIR HANDLING UNIT CTD 10,000 CPM) SUBTOTAL:
agahut.ala rat in sen m fthe granting of this perm) AIR HANDLING UNIT(OVER 10,000 CIM) CONSTRUCTION TAX
/�
SJX.W,i of Applor Date IXHAl15T HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will ia the definedb the future bolo ngompamatom hapten lehaandous HEATING UNIT(TO 100,000 BTU) Date Recei t#
Health
Safety
by the Cupertino2(a)? al Code,Chapter 9.12,and the
Healthaa Safcty Cade Section 2S532G)7 HEATING UMT(OVER 1W,000 BTN IOTA l
Yea No
Willthemt hannintorfuture
artarnunts as defined
ndby the Bay Area devices VENTILATION PAN SINGLE RESID) ISSUANCE DATE
which emitnaementsatrrict? anis as de0ned by the Bay Arca Air
Quality Management District? BOILER-COMP DEEP OR 100,000 BTU)
4 Yrs 1—I No q
haif.1.1h.lth&`rSifOmatcri Sfdi. 25505tsundea.d255er6.95 of BOILGR-COMP(OVFR 100,000 BTU) n� �y'
theerstfomiaatlith k building
Code,Sealonsntly have
a tenant,
that 34.
l understand Quo notify
the occupant
not eropub .amts which
that it met NEW RESIDENTIAL MECH. SQ.FI Ii D Q /�
mor to
responsibility issuance
of aCeheicate o Occupancy. rcmenb which must be met '7 `a \/\IhC`�//\—J,
prior to issuance of a Certificate of Occupancy.
vl'r`�L�N 9
Ownermauthorludagent Date ISSUED BY.q •
TOTAL Y��s�—�
OFFICE COPY
SAO BACKFLOW PREVENTION ASSEMBLY-TEST REPORT
San Jose RETURN NO LATER THAN
Water —,
Company
MAILING ADDRESS ASSEMBLY INFORMATION
NAME nI L_=� } •, r,c TYPE (�.-(1, F'3. SIZE I IZ_ M\F/G rt C '
ADDRESS MODEL QZ A SERIAL NO. 7 5 7Z ;
CITY,STATE, ZIP PASS FAIL ❑ SEE COMMENTS ❑
SERVICE ADDRESS IS C O t' I C v E ' I v (�I S
ASSEMBLY LOCATION:
G
METER NO. -� [�� -� _� F'. -7Z_ `. ACCT. N0. U C1U - 4 E'i c1 - j Z- Z j - Z
REPORT OF TEST RESULTS
DOUBLE CHECK VALVES PRESSURE TYPE
VACUUM BREAKERS
REDUCED PRESSURE ASSEMBLY
CHECK VALVE CHECK VALVE PRESSURE RELIEF AIR INLET CHECK VALVE
NO.1 NO.2 VALVE
CLOSED—7TIGH[T� CLOSED TIGHT OPENED AT �j . D OPENED AT_._ CLOSED TIGHT ❑
INITIAL (RP)oto Pslo PED (RP) PsiD
TEST
OPENED UNDER OPENED UNDER
LEAKED ElLEAKED ❑ OR DID NIOT OPEN ❑ OR DID NI OT OPEN ❑ LEAKED ❑
1 CLEANED ❑ 1 CLEANED ❑ 1 CLEANED ❑ 1 CLEANED ❑ 1 CLEANED ❑
R 2 EXERCISED
E REPLACED REPLACED REPLACED REPLACED REPLACED
P 2 DISC 2 DISC ❑ 3 DISC(S) ❑ 2 DISC ❑ 2 DISC ❑
A
3 SPRING ❑ 3 SPRING ❑ 4 SPRING 0 3 DIAPHRAGM ❑ 3 MODULE ❑
4 GUIDE ❑ 4 GUIDE ❑ 5 DIAPHRAGM(S) ❑ 4 FLOAT ❑ 4 OTHER ❑
5 SEAT ❑ 5 SEAT ❑ 6 SEAT(S) ❑ 5 SPRING ❑
R 6 MODULE ❑ 6 MODULE ❑ 7 0-RINGS) ❑ 6 OTHER ❑
S 7 OTHER ❑ 7 OTHER 8 MODULE ❑ ❑
9 OTHER
FINAL CLOSED TIGHT ❑ CLOSED TIGHT ❑ OPENED AT OPENED AT_ CLOSED TIGHT ElTEST (RP) Psio Pslo
PSID
PSID
THE ABOVE REPORT IS CERTIFIED TO BE TRUE.
TIME OF INITIAL TEST: TIME OF INITIAL TEST:
STAfII _ END START END
INITIAL TEST BY:_ /1,C/' L__.7� (1 ( 1.( j CERTIFIED TESTER NO. / DATE /� (1 rl Z
. FINAL TEST BY: CERTIFIED TESTER NO. DATE
M611 To: SAN JOSE WATER CO COMMENTS:
METER SHOP DEPT M9
1251 S BASCOM AVE
SAN JOSE CA 95128
ATTN: CROSS CONNECTION CONTROL
FOR FURTHER INFORMATION PLEASE CALL(408) 279.7937 OR (408) 279-7938