25224 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B-111.11 -el.BL MICAI. PERMITNO.
5 n n
APPLICATION/PERMIT PLUMBING-MECHANICALCT
BUILDING DIVISION BUILDING PROJEWEN'TIFICATION' J G G 4
BUILDING ADDRESS: SANITARY NO. APPI.ICA'DON SUBMITTAL DAII7
UNIT# LOT#
OW SNA E: •PHONE: CONTRA It'SNNAME: LION
N/C CONTROL p
10
®AHCIIITECI'/' GINLER: LIC NO, I A .S.'
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
❑ BLDO ELECT PLUMB MUCH
PERMIT ISSUANCE Z,�p ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
QWz Thereby alEnn Wml:un license)anderpnrvlxinnsof Cbupter9(n+mmnencingwi0
W00 Section 7")of Division 3 of the Business and ProfessionE
Professions Code.and my license is in PANS
_ full force and If t '/-'�
6FZ, I.iccn Class .,tea Lic.p I /f. UP TO 20p AMPS -�T,/ IF
—V
Date Cnmacmr 201,IOIyIAMPS l
1—y Z ARCHITECTS DECLARATIONSQ.FE FLOOR AREA $/SQ.FT.
I understand my plans shall be used as public records. OVER ItXp AMPS
0 z—M Z—❑uj SIGNS ELECTRICAL
Q��, Licensed Prnfcs.innul
We,< OWNER-BUILDER DECLARATION SPECIAL CIRCULI'/MISC.
xOaU I hereby affirm that I am exempt from the Contractors License Law for the
m3ay followingmc%on.(Section]O3L5,Busines-and Professions Code:Any city or county TEMP.METER OR POLE INST.
which requires a permit u.eanswa,alter, prove,demolish,or repair any structure
yt2Q7 P,mma,,iuuance.als.require.thea P t fursuch permiuofile asignalmocancht POWER DEVICES
�0.'0p that he is licensed pursuant to th pro tithe Contactor's Liceve law(Chapter SWIMMING POOL ELECTRIC VALUATION
9(commenr' gwiO Section'/ )o L n 3af 0e Business and Professions Code)
❑y nr lhm M1c is xmnpt a osis to,(M1calleged exemption.AJn Iminn of
1—ZQ Stir TO .5 y y: foapcnnitsubjecuthe a t it]penalty of OUTLETS SWII'CHPS-PI%'LURES
norm t f un doRars�L o rhithepm r yemp Ye ithaKg ci I pammum. NEWRE,SIDENTIN.ELECTR _SQ.FT. STORIES TYPECONSTRUCDON
e—° willdoth, k,and11J� Ioic, ark, d fierce for. Ie( M4,EasinssvnJ Profess rs Cad s,m trg as t apply aver owner of
,.,,whubulldsn, p wfficreon, d whodocssuch work himselfor0uough his
cmpinyees,prmi dtbm sucM1 improvemcrosare not imm�ddhrofferceforale.IL OCC.GROUP RFS.UNITS
however,the ha dingorimpnwemont is sold w din one year nfcomplmian,the owner- TOTAI:
builder will have the burden of proving that he did not build or improve for purpose of
`ale')' QTY, PLUMBING PERMIT FEE FLWDZONF: APN
❑ Los ownerofthe propm property,aenclusivelycunuacting with licensed characters
co Dart(hc project(Soo.7044,lousiness and Profession,Codc:)*Om Contractor's
License Law d«snot apply tout ownerofpropeny who builds.,improves thereon,and PERMIT ISSUANCE
whocantan
ctsforsuch projects with achnacmHs)Iicwsod punuanu,the Contactors ALTER-DRAIN&VENT.WATER(EA) FEESUMMARY
License Luw.
❑ 1 am exempt nndcr Scc. .D&P C for this reason BACK FLOW PROTECT.DEVICE SANI'IAHY Y OUTSIDEF171
N
+ Owner Dare DRAINS-FLOORROOFAREA.COND. RECEII.1'p
WORKMAN COMPENSATION DECL , ,
ARATION SCHOOLTAX Y N
❑ Iherehy affirm that l have acenificateofconstato self-asure,oracerificaten( FIXTURES-PF.R TRAP RECEIPTN
Wommi Coapenation lnsurnar•,eoracenifiercopy Nemal'Sm.3800.LabCJ which PARK FtB YN
coven all employs', ties 's e,m CAS-FA.SYSTEMI INC.40l1TLETs RECEIPI'p
P,IicY# BUILDING DIVISION FEES
Company / GAS-EA.SYSTEM-OVER4 HiA) PLANCHECK F'FE
❑ Cenifie4 cop is hereby tumished.
CerifiW copy is filed wish the city inspation division. GREASEBNDUSTRL WASTE INTERCEPTOR GRADING RE
CERTIFICATE OF EXEMPTION(ROM WORKERS' GREASE.TRAP SOILS FEE
COMPENSATION INSURANCE
Qbis section need not be completed ifthe permit is for one hundred dollars($100) SEWER-SANITARY-STORM G.20017. ENERGY FEE
or less.)
I moody that in the performance of the work for which this Permit is issued,l shall WATER HEATER WNENT/ELECfR
nam employ any person in any manner so as to become subject to the Workers PAID
Compenatihml-awsof California. Date WATER SYSTENVIRFATING Date Receipt#
Q z Applicant
z0 NOTICE'1'O APPLICAN'T:If,afaamaking this CeniOcam of E.emptian.you should NEW RESIDENTIAL PLMB. SQ FT. TOTAL:
(•-' Cl) Become;object to the Worker's Compensation provisions of the Labor Code,you must
BUILDING FEE
7 forthwith comply with such provisions or this Permit shall be deemed revoked.
W Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm(list there is a construction lending agency for the Perfomhence of
M Z, TOTAL: ELECTRIC FEE
U O the wok for which this permit is issued ger.309?,Civ.CJ
I<ndcr's Name PLUMBING PEE
u-' F Lender's Addrcs QTY. MECHANICAL PERMIT FEE
U I crafty that I have read this application and stain that the above information is \ MECI IANICAL FEE pD
W chimer.l agree to comply with all city and county ordinances and store laws relating to PERMIT ISSUANCE, GwB S•
C1. building construction.and hereby a ammo,mpreacnmtives ofthis city wester upon the
CONSTRUCTION TAX
U 'Z shave-memianed pmper(y for inspection purposes. ALTER OR ADD TO MECU.
no
agree to save,indemnity it keep ha,mlens the City of Cupertino against
liabiliti .juJgmenu.cos tenses which may in any woyxere against aid Ciry AIR HANDLING UNIT(TO 10.00)CFM)
in co�of yyyllleg nB aF this permit.
�S� AIR HANDLING UNIT(OVER 10.000 CFM)
Signature of Applicamt/C ctor Date EXHAUST HOOD(W/DUCIT PAID I:::
-
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) (Iv pD Date' Receipt#
Will the applicant or future building occupant store or handle ha<ardous material HEATING UNI'I'(OVER 1(q,fgq BTU) 'TOTAL:
as defined by the Catarina,Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532Ta)? VENTILATION FAN(SINGLE RESID)
❑Yes ❑ No
ISSUANCE DATE
Will(heapplicantorfuarebuildingoccupant usee,tipmentordevices whichemit BOILIiR-COMP(311POR IW,000 BTU) P A 8 ...j�
hueaMous air conwminants as defined by the Bay Arca Air Quality Manogement BOILER-COMP(OVER 101,000 BTU)
District?
❑Yes ❑No NEW RESIDENTIAL MBCA. SQ.Fr. JAN Q JO 1nn5
1 have read the haarmu
dous materials mydnenunder Chapter 6.95 of the (•! a7
California Health&Safety Code.Sections 25505,25533 and 25534. 1 understand that
iftheballdingdoesnot currently have a mount.that it ismy responsibility to notify the CII r yr wrrn IINU
«mutant gqutrc t hi t h met poo1.issuance nce of o Certificate of
Occapa. 1�e
mor uutlmorire<I agent Doe TOT'Ah: L)p ISSUED BY:
C- -lperl ino
10300 Torre Avenue
Cupertino, CA 95014
Building Division
(408)777-3228
Fax(408)777-3333
November 29, 1995
Resident
19834 Merritt Drive
Cupertino, CA 95014
Subject: 19834 Merritt Drive, Permit# 25224 - Furnace
Dear Resident,
• According to our records the above mentioned permit has never been finaled by a
Cite 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
p1dase 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
Pnnled on Recycled Paper