S 0358 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PF1 IT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL J 0358
BUILDING PROJECT IDENT'IF'ICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUHMITI'AL DATE.
D 31 M09.& Dem► vel. C.0 a CA
OW ER'S NA PHONE: C TR C1'OR'S IJA E: LIC NO:
a� NIC 1�.C.O..�NaaT�R`OL M
12 12- `•A I' .C'/ENGINEER: LIG 5 L. RESti: a ❑
coNrncT PHONE: Si. FAI 0 BUILDING PERMITINFO
patr►ee ,;� ❑ Consultant Fees Paid by Applicant(Initial) BLU, ELECT' PLUMB MEC
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRICPERMIT FEE JO�CRI TION
1 hereby affirm that 1 am licensed under previsions of Chapter 9(commencing
Dat with Scction7(gpinf Division 3.1 the Himmexeand Professions Code,and my license is RESIDENTIAL:
1-- 0 full farce and effect. PERMIT ISSUANCE. ❑SFDWL ❑KITCHEN REMODEL
License Clnss Lic.M
Zy) Dae Conlraclm APPLIANCES-RESIDI3MTIAL C1 ADDITION ❑PLUMBING RE-PIPE
�Gd ❑MULTI-UNIT ❑STRDLTDRAI.
ARCHITECTS DECLARATION
g.�to PANELS MODIFICATION
Z p 7,- I understand my Plena shall4 used as public mmMs
OZ—, Oil T02tp AMPS El INTERIOR C1 CHIMNEY REPAIR
r4�E Licensed Pmfessiannl 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
aq OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMoUELfREPAIR ❑DEMOLITION
iq
1 herehy tiffte rthat I an
exempt team the Contractors License Law for the ❑OTHER S O U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL
w 3 2 F- which requires a Permit to construct,alter,improve,demolish:or repair any structure
F�Or3 pdmm itsissuance,almtequirestheapplicnnt forsuch Pemti a.fileasignedstatement SPECIALCIRCUI'UMISC.
y Ibm he is licensed putxuam m the provi.slomaf the Commencs License Law(CTapmr9
aan (commencing with Section 70(s)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
d y e C that he is exempt thercfmm and the basis for the uilegcJ exzmption.Any violntian of ❑N W BLDG/AUDITION [I DEMOLITION
LLXI 4•
Section 703 1.5 by any applicant for a Permit.omectsthe applicant In a civil Penalty of POWER DEVICES ENANT FOOD SERVICE
pZOm ant. roman five hundred dollars($500). 1 ROVEhDINT
❑1.as owner ofthe property,or my employees with wages us their sole tnmpensatinn, SWIMMING POOL ELECTRIC OTHER
jd willdathe wcak,undllmoncmre is nm imendednrnRered faudc(Sec.]fg0.Busirest
W and Pmio
fcssns Codm
Code:The Cnmmctm ow
s License Law docs not apply to ner of OUTLETS—SWITCHES—FIXI'U .S
d 3^ property what builds or Itnprevcs therein,and who dues such work himself nr Ihnmgh
his own employ",,provided Ihm such improvements ere not intended or offered for NEW RESIDENTIAL ELECT S
sale.If,however the building or improvement is sold withinnne year of crmptonn.the SQ.FC FLOOR AREA S/SQ.FT.
er-builder will have the burden of moving that he did not build or improve for pun
pose of sale.).
I OTAI"
C]1,as owner of the Property,ore exclusively contracting with licensed cocontractorscontractorsm .^�
construct the project(San.7014.Business and Pmfessinns Code:)'I he Comractor's Li-
Law does not apply mnnowner ofpropenYwho builds orimpmvesthemon,and QTY. PLUMBING PERMIT FEE
who contracts forsuch projects with a connaeor(n)licensed pursuant o the Contractors
License Law. PERMIT ISSUANCE
I an exempt under Sec. .R&P C for this reason
ALTER—DRAIN&VENT—WATER(FA) VALUATION
Owner Dale # IS;S 000
WORKIiR'S COMPENSATION DECLARATION BACK FLOW PH(7fECT.DEVICE
1 hereby offum under penalty of Perjury one of the following declurationa.
❑Ihave and will maintain a Certificate ofComalto self-insure for Workers Compen- DRAINS—FLOOR,ROOF AREA,GOND. STORIES TYPE CONSTRUCTION
cation,as Provided far by Section 37M of the lalsor Code,fir the performance of the
work far which this permit Is issued. FIXTURES—PER TRAP
❑I have and will maintain Workers Compensation Insurance,as roquimd by Section
37011 of the Labor Code,for the performance ofthc work for which this permit is issued. GAS—G.SYS TEM-1 INC.4 OUTLET'S OCC.GROUP APN
My Workers Compensation Insumace carrier and Policy number am:
Cartier: Policy No,: GAS—G.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE/1NDU5'fRl.WASTE INTERCEPTOR
COMPENSATION INSURANCE tILDIN' 1.' F ES
('Ifiissectionneednmh completedifthermitisfnronehuMd dollms(flip) GREASETRAP
mless.) PI FBL /r
I certify that in the performance ofthe work for which this Permit is issued,I shall SF.WIiH—SAN]"TARY—SFORM F.A.200 fT.
not employ any pwom in any manner so as m become subject the Workers'Cimpen- 7 GY iE
union lawsof Cidifxiia.Data WATER HEATER WNENT/ELECtR
Q Applicant GRA
F-' ^ NOTICE TO APPLICANT:IC after making this Certificate of Exemption,you should WATER SYSTEM/TREATING
become subject to the Worker's Compensation provisions of Ne Latin Cash.you must SOILS MI
G fnnhwilhcon,ly withwelt previsions or this permit shall he deemed rtvoked WATER SERVICE
U z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL.PLMB. SQ.FT. PAID qa Recei t p
UOI for which thi thmmemissued construction lending agency for the penbrtnanceof Q P
F-' the wad for which This Permit is issued(Sw.JIN],Civ.C.) ,TOTAL
QU Leaders Name
W Lender's Address 'frTl'AL:
0. I cenify that 1 have read this application and state that 0e aM+vc information is DI
Fry correct.l agree to comply with all city and county ordinances and Stam laws relining al QTY. MECHANICAL PERMIT FEF.
U � building construction,and hereby aothorien mpmsenmtivesofthiscilymemeruP nthe SEISMIC Ft
above-mearmand property for impeeinin purpuus. PERMIT ISSUANCExx
xx
(We)agree m save,indemnify and keep harmless the City of Criterion againstIIEL�'.CT'HTCIiuhiblies,judgmeals.costs and expenses which may in any way accrue agai n.st said CltY LTHR OR ADD TO MECH. PLUMBINin consequence of the granting of this permitAPPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000CPM) MECHANI
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER I0,000 CFM) CONS'TRUCTION'TAX
Sigratemof Applicanl(Contmcmr Dore EXHAUST HOOD(WNUCT) HOUSING MITIGATION11:E
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant Imre or handle haesNous material HEATING UNIT IT 01 c0.000 BTU)
as defined by the Catania Municipal Code,Chapter 9.12,and the Health and Safety
Coda Section 25532(a)'1 HEATING UNIT(OVER 100,0g01)BTU)
❑Yes 71 No VENTILATION FANS INGLE REST D) - PAID
Date Receipt a
Will the applicant or future building occupant use equipment or devices which
emit bamrdous air contaminants as defined by the Bay Area Air Quality Management BOILER—COMPOHPOR 100.0Ip BTIA TOTAL:
Diuricf! BOILER—COMP(OVER 100.000BTU)
❑Yes ❑Nn
I have read the hmarJnus materials tequ e,mems under Chatter 6.95 of the Cilli- AIR CONDITIONER ISSUA A
mad.Health&Safety Code,Sections 25505,25533 and 3534.1 undcrsmnd that if the NEW RESIDENTIAL MI'CH. SQ.FT. 3 O
building does not currently have a tenant,that it is my responsibility to notify the eccuptnt v-
of the rgtdremems which must be met prior to issuance of o Cerificale of 0crapuncy.
Owner or outhodmd agent Data TOTAL: ISSUED BY:
OFFICE