99100123 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY C-I C/ I )n/"7,2
CITY OF CUPERTINO BUILDING-ELECTRICAL. �1 PErRMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMAINO-MF,CHANICAI. SOOO1
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: t SANITARY NO. APPLICATION SUBMITTAL DATE
6 G rns orGt° �D r. 6 2 ?(1;'
WEER:S NAME: PHONE: CO TRACfOR'S NA F.: LIC NO:
� /Ir IQSON S �z NIC CONTROLN
f RCHITECTANGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Bz with Seninn4011p)of Dwinon 3ofthe Brea ess,ad Professions Code,and my lice RESIDENTIAL:
F
10 0 in full force and affect. PERMIT ISSUANCE ❑SPDWI. [I KITCHEN REMODEL
�UUU DolLice
Class LIGM APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
F�Ir1 Dice Contrvmor
N n' ARCHITECTS DECLARA ION ❑MULTI-UNIT Ll STRUCTURAL
(•� y PANELS
z O m TJ I understand my plans slmll be used as public records MODIFICATION
OZ-,
UP TO 200 AMPS E3 INTERIOR &-eVRINEY REPAIR
�1�; Licensed Professional 201-IOWAMPS IMPROVEMENT L]SWIMMING POOLS
Iy,'E..l OWNER-BUILDER DECLARATION OVER 1000 AMPS EJ BATA REMODEIREPAIR ❑DEMOLITION
C W 6 1 hereby affirm that 1 am exempt from me Contractors License Law for the
aO t U following octsm.(Section 7031.5,Business and Professions Code:Any city m county SIGNS ELECTRICAL ❑OTHER
[L F which requires a permit to mmsrnm,eller,improve,demolish,or repair any structure
prior te he issuance,also requires the applicanlfor such perminn file aligned statumem SP IAL CIRCUITIMISC.
'hot Ile tl' dp sus a the provisions of the C tII Lw(Chvpter9
GDy (cam e g 'm Sett 900) fD 3 fth B e dP f Cvte)or P I sle, .- II COMMERCIAL;
Q. c 4 that h pt therefrom d theb f the pt Any'i
y ' I t on of 1 NEW BLUG/ADU ITION C DEMOLITION
iry5, 4•
Section 9031 5 by any ppl t f p t. ij I ih applicant t I Penalty f p �1 E I
n•I�tn - s{^I 9 TENANT ❑FOODSERVICE.
Spnal more than fee hundreddollars($500), IMPROVEMENT
❑I o the warmf the propeny y ply ro e 1 pe s Y SWIMMING POOL CTRIC
F and othewoak,ander structure tintended es If ises n I (S 11, a Bn' es eix - DOTHER
3 m and Professions Code:iThemp Canrvuors License Law does no,apply s if owner or LETS C
R' .. propeny who boil,,or improves thereon,and who aces'm a weak himself,,or through
his own employeese provided that such mens is old w me not initiated ofe or offered for
sale.If,howeveq the building or improvement is sold within one year of cmnpletion,the SQ.FT.FLOOR AREA SISQ.FI'.
owner-builder will have the huNen of proving that he did not build or mouse for per,
pawi,. cele.).
❑I,its owner of the property am exclusively connmling with licensed commcmrs m
commit the t(Seo.9044,Business and Profession,Calr:)The Commitor's Li-
came
i-
snotsen
seLuwdtsfors apply toas with
of property who bedporimproves the Contractor
QTY. P BING PERMIT
who contracts for such pmjwts Lim a wntraetnr(a)licensed parasol to the Cnmmnnr'n
License Law.
❑Inco exempt under Sec. ,B&PCfor this reason PF:RMIT•AVf'CE
lwner Dale
ALT11
-DRAIN&VENT-WATER(EA) VALUATION
i
WORKER'S COMPENSATION DECLARATION XACK FLOW PROTECT.DEVICE
alIJ�\
✓ Ihereby lirm under penalty of perjury one of the following declarations; CJ
E] I have and will maintain o Cerificam nl'Consent to selbirsere for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND.
sound,as provided far by Section 3900 of the Labor Cede,for the performance of the
STORIES TYPE CONSTRUCTION
work far which this permit is issued. FIXTURES-PER*1'RAP
F] 1 have and will maintain Worker's Compensation hermace,as require,by Section
3]W of the Labor Code,for the performance of the work for wM-
hich this permit is issued. GAS-EA.SYSTFIINC.40UTLETS OCC.GROUP APO
My Worker's Compensation Insurance carrier and Policy number are:
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA) 00,
CERTIFICATE.OF EXEMPTION FROM WORKERS' CREASIDINUUSTRL WASTE.INTERCEPTOR d
COMPENSATION INSURANCE. BUILDING DIVISION FEES
('Phis sedinn need not be completed lithe foram hundred permit is forahundred dollars IS 100) GREASETRAP
odessJ PLANCHECK FE6
I certify that inthe islayormvmeofthe uesable Toni ch this Fusitis.Icasued,lsaoll
- SEWER-SANITARY-STORM F.A.200 Irl'.
not employ any
pe any rat ner n as to hecot Fuss Comped- ENERGY FEE
O Z lotion Lu s ��C�1� J� E WATER HEATER WHEN UELECTR
Z2 Applican �'y uu' (IRADINGFF.E
PF-t F�-t NOTICE T APP�-LIGAN'IL after making this Cer team of Exemption,you should WATER SYSTEM)TREATING
become subject m the Walker,Compensation provisions critic Labor Cale,you must SOILS FEE
IJJ fonhwhM1 comply with such pmmnoos or this permit shall be deemrrim,.leal. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,P. PAID
UO k for
rte thatthemmitisisued(Season lentog agency for the performanec of Dnre ReceipiN
wF the work for which this permit is issued(See.3W7,Civ.CJ �-
O U Lender's Name /i 1Z\
nTO A
lenders Address TOTAL: -'-
a1 certify that 1 have read this application and state that the above information is OTLE)MG FEE
Un Names.)same,,comply withal)city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE tz� n
U t� building construction,and hereby authorize representatives of this city m F F. -(t (s
enter upon the SEISO]E
lqqq
thava-mentioned pmpeny for inspection purgmses. ,x
(We)agree to save,indemnify and keep harmless the City of Criterion against PERMIT ISSUANCE ELECTRIC FEE
liabilWas,judgments,costs and excenses which mu 'way name against said City ALTER OR ADD TO MECH. .PLUMBING FEE
in asequence of the granting of this permit. :j
APPLICANT UNDERSTANDS AND W OMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,900 CFM) -'
SOU R GUI -^MEQHANIGhL-It'
7 AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
9igm ore nfA plicanUCntrnemr Date EXHAUST HOOD(WI HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicum or futurebolaing occupant smreorhandle howNnosuratedal HEATING UNIT(TO 100.000 BTU)
as defined by the Cupenme Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(v)'I HEATING UNIT(OVER 100LO p BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Gare Racoulda
Will the it contaminants
or fnmm building occupant use equipment of Management
which BOILER-COMP DUE OR 100,000 BTU7
[nit hazardous air mnmminan[s as Defined by the day Arca Air Quality Management TYyfAC �
Di i[?
❑Yes 7N BOILER-COME(OVER IfN1,IXNI BTU) ,
AIR CONDITIONER
1 hove rwd the hazallous mamriWs wouircmems um huEach
ter 695 of the Cali- ISSUANCE DATE
forma Bealth A Safety Code,Sections 25505,25533 an 534.1 understand thus if the NEW RESIDF.NTIAI.MECH. SQ.Ff. O Z •7 C7
huildingd enI IF m,that it is "it tonmifytheoccrpant C� T
of tha req He c wh' m n dprinrtu is. scent ficate of OCCu nc
9.Z1
Lost or mathemuedsagent Dam TOTAL: ISSUED BY.
OFFICE