S 1281 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-EE.ECTR1CAL PE IT NO, q
BUILDING DIVISION APPLICATIONMERMIT PLUMBING.MECHANICAL 1281
RUIIAING PROTECT IDEN11AFICATION
BUILDINGADDRESS: SANITARY NO. APPLICAI'IDJ(SN SUBMITI'Ah HATE
-2Zrr�
W ER'S SIAMM PHONE: CON IRACTOR S NAME: '�1(� LICNO.
O O NIC CONTROL p 19 A,
RCHITEET ENGINEER: Lit NO: ADDRESS:If (P4 IO ❑
(d 3 5
CONTACI`. PHONE: BUILDING PERMIT INFO
. ❑ Consultant Fees Paid 6y Applicant(Initial) BO ELECT PLUMP MEC I
LICI4JSEDCONfRAC1T3R'$DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby alarm Ina,1,61 beemm mlder,owk nos of chanter 9 memmendag ]OB DESCRIPTION
O00 wBh Semon 700(finflali,kn3oDbe B,Tebmsxand Pndesslnnc Codc,mnd toy license is RESIDENTIAL:
O O I'ERMI'I'ISSUANCE
CSG
in force and eR ❑SFDWL ❑KITCHEN RF,MODEI.
QFUZU
Liven Class .X APPLIANCES-RES[DENTIAL ❑ADDITION [I PLUMBING RE-PIPE.
N d L Dom Cnmrncm
AIICHITEC"DE ❑MULTI-UNIT ❑STRUCTURAL
F D m PANELS MODIFICATION
ZOHZ IunderswnJ mY Plunc ehallbeuseJ as public ren Nx
OZ4O UP'1021X)AMPS Fl INTERIOR ❑CHIMNEY REPAIR
W Licensed Proac,simtvl 201-10MAMPS IMPROVEMENT C]SWIMMING POOLS
gyhdE� OWNER-BUILDER DECLARATION OVER I(NXIAMPS ❑BATH RF,MODEIIREPAIR ❑DEMOLITION
C C 6 I herchy animated I am exemp,from the Contractor's License Low for the
6060 fnllowin Sec,ion]031.5,Business and l'mfessions Cale:An cit In [--]OTHER
g reason 6 Y Yor county SIGNS GL[CI'RICAL
LL u0 y which its ssu a pemmil to conswn,ulme improve,demolish,nr repair any suuc,urc
that heor incensed ursu requites lhovisio so IthemcM1parminotilnse Law(ned stmemem SPECIAL CIRCUIT/MISC.
ad-, ,hut he is licensed pursuant to the provisions ul the CareernKsl.icenx Lew(Chapter I))
�y'p� (commencing with Seniors IIXXR of Division 3 of the Business and Profession.Codger TEMP.MEI'ER OR 1'OLF.INST. COMMERCIAL:
d y o y that he is exempt IM1erefrom.,it the oasis for the alleged cacmp,ioa Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
uX] lay Section 7031.5 by say applicant lido permit subjmtslheapplimn,me civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
�Zy„ I more than Eve hundred dollar,($500). IMPROVEMENT'
M DLasowncraf,he prapm,u,my employers with wages as Tben,ole nnmpensation, SWIMMING POOL ELECTRIC
SI- will do the work,and,bestrucmre is nm intended proffered orsele(Sec.7044,Business ❑OTHER
63 m and Prnfesions Ctde:'I'he Cummunim,License Law Jan not apply I,:at owner of OUTLETS-SWEUTRS-PIX'IC :.
pnspeny who builds or improves thcram,and who does such work himself or Ihrugh
his own employees,provided that such inmprovcmcma am not intended or offered for NEW RFSIDEN'PIAL HLIEC R 10!5
safe.I F.however.be hot Wing or improveranl is sold within one year of completion.the SQ.FT.FLOOR AREA $/SO.W.
owner-builder will have The burden of proving that he did not build or improve for pmr-
poss of sole.).
1,as owner of The property,not exclusively contracting with licensed convenors m TOTAL:
conn u t UTe pmjee,(Svc 7144,Business and Professions Code:)The Contractor's Li-
cmmseWwdoes Pat apply manowner ofproperty%no builds or improves mheaon,and QTY. PLUMBING PERMIT FETE
who contracts for such projects with a contrawants)licensed pursuant In the Contractor's
License Law. PERMIT ISSUANCE
❑I am exempt under Sm. ,B di l'C for this reason
Owmm Date ALTIER-DRAIN&VEN'P-WATER(EA) VALUATION
WORKER'S COMPENSATION DECIARXION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the bellowing declaration:
El I have and will maintain a Cerificaw ofCooanno sell'-insure lox Workers Gnnfwm DRAINS-1Djontialiiii, $TOBIDS TYPECONSTRUCfION
sation,as provided lox by Section 370)of the Labor Code.for the performance of the
work for which thin permit ixoOned. FIXTURES I
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3MBmfthe LaborCodc,for the perlbnnantt of The work l newhichthispemnit is isvmA GAS-EA.$ 1 CA S OCC.GROUP MIN
My WakWW'ss���'Q��'� y �am J I'nlicy ryryuJJ byrl/rr
Carder:S.b I �aLr"dicy No.:a wk 00010i GAS-EA.SYS'IEM-OVER 4(EA)
CERTIPICA'1'E OI'EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE. GRIEASFJINUUS'1'Rh WASTE INTIERCEPIY)R
BUILDING DIVISION FEES
(This seClinn need nr,Iwwtnplcted if mhc permit is Lnonu hundred dollars(EI00) GREASETRAP
or
less.) PLANCHISCK PEG
I moily that In the ferformmac ofthe workfin-whichthis permit is issued,l shall SEWER-SANITARY-STORM EA.2M FE
no,employ any person in any nmanner so as to become subject to the Workers Compen- ENERGY FEE
�Z xatiun laws of Caladraaa.Data WATER HEATER W/VFNT/IELGCTR OQ
O Applicant GRADING FEE
Vj
Nat ICE TO APPLICANT.IL after making this Ceniricatc of Exemption,you should WATER SYST HM/IREAI'INC,
F become>object to the Workers Compensation Provisions of the Labor Cade,you nm.0 SOILS FEE
Wforthwith comply with such provisions nr this permit sha116e deemed revoked. WAfER SERVICE
a �
CONhem isa'IONLENDINGACENCY NEW RCSIDENfIAl.1'LMR. SQ.FT. �
z pmt•` , Receipt Is
L) k for
rwhichirm thmlhereissued(Sm.30lending agency for the performance of
the work for which This permit is issued(Sum.JB9].Civ.CJ $
U Lenders Name TOTAL:
V Lenders Address TOTAL.
0. nocertify Nat 1 have rtaJ,his application and state that the shove inlommmion in BUILDINGFEE
F' N correct.l agree to comply with all city and county ordinaam,:rad ,am laws r,Wingw QTY. MECHANICAL PERMIT FEE
V buildr,mavwnTon,and hereby mantra spoconmtivm of tbisci,y to emmumor the SEISM IC FIFE
above no ntionetl pmpany for inspeenon purposes. PERMIT ISSUANCE:
(We)agree to save,indemnify and keep harmless the City of Criterion against ELECfRIC FEF.
Iiabili,ies,judglnents,costs and expenses which may in any way acerae against said CityALTERORADDTOMECH.
I.consequence of rhe grating of this permit. PLUMBING F[E
AP'PLICAN'T UNDERSTANDS AND WILL COMPLY WITH AL1.NON.POINT AIR HANDLING UNIT(TO 10.000 CFM)
SOURCE REGULATIONS. MECHANICAL LER
AIR HANDLING UNIT(OVER 111.(X10 CFM) CONSTRUCTION TAX
SignomrcnfAppli,mr/Conmtnor Data EXHAUS'P HOOD OVIDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicnnt tit future building occupant store or handle hazardous material HEATING UNIT(10INDOOR)BTU)
as dclined by the Cameroon Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532m)7 HEATING UNIT'OV
ER IM,M0 BTU)
❑Yes E]No PAIIy
VENTILATION FAN(SINCiLC RESID) Dam Receipt If
Will the npplicaml or fhlure Wilding occupant use equipment or devices which
nit hazardous air connotations as defined by IM Day Area Air Quality Management BOILER-COMP(311P OR 100.IIIXI BTU)
TOTAL:
District? BOILER-COMP(OVER IMJRM R'PU)
❑Yes Fl No
AIR CONDITIONER
�) Ihave mail the hazardoust as
s255regaire33 an under Chapter ofthe Culi ISSUANCE D E/�
dnmia Health,d.&5011 Ctd4 S•c,inm<25505.25533 and 25534.1 understand indfyth Thnt if the NEW RESIDENTIAL.MECH. $Q.hT. (I 1J/(
bnildingtlasn , I• m gees onsihility n,nmifythuaupam
nflbe a xsxry�/ 9 r rtonfn Cenitirnc of[kmipancy.
SIB
Dw fianze eat �r Doe TOTAL: 1SSUEDBY: urs -
OFFICE