29813APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
Ru1LDING DIVISION APPLICATION/PERMIT . PLUMBING'1fECHANICALT / Q
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NGINEER: LIC NO:
ADDRESS:
4 r
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HEATING UNIT (OVER 100.000 BTU)
PAID
Date eceiPtp
O G1
BOILER -COMP (JHP OR 1 W,OW BTU)
TOTAL
BOILER -COMP (OVER Iboom BTU)
CONTACT: PHONE
V-
BUILDING PERMIT INFO
NEW RESIDENTIAL. MECH. SQ. FT.
❑ Consultant F"s Paid by Applicant(Initial)
BID9, ELECT -PLUMB MOH
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I um licensed under provisions of Chuper 9 (caminencing
with Seainn](KKry,f Divisian3of Ne Business soil Pr,lbsouris Code,andmylicerwis
royalfoace
Licrnu laanlcffrd.
LicaSim F
Dam Contratar
ARCHITECTS DEC T
1 u alco and my plans shall be used as public records
QTY ELECTRIC PERMIT FEE
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OERIOR
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- JOB DESCRIPTION
RESIDENTIAL'
T
❑SFDWL ❑ KITCHEN REMODEL
❑ADDITION ❑PLUMBING RE -PIPE
El MULTI -UNIT ❑STRUCI'fIRAL
MODIFICATION
11 CHIMNEY REPAIR
IMPROVEMENT
❑BATH RBMODEVREPAIR El DEMOLITION
THER
PERMIT ISSUANCI?
APPLIANCES - RESIDENTIAL
PANELS
UP TO 200 AMPS
Licensed ProfessionalOWNER-BUILDER D[Cal
ontr, ON
1 hereby amort that 1 cert mm thee Commcxnpt froemrs detest Law for the
following reason. (..than ]ID 1.5, Business and Professions Code: Any city or county
which requires v permit m consortia. ulcer, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant far such permit to file a signed statement
that he is licensed pourstrand to the previsions ofthe Contractor's license Law (Chapter 9
201-1000AMPS
OVER Ittgl AMPS
SIGNS ELECTRICAL.
SPECIAL CIRCUITIMISC,
TEMP. METER OR POLE INST.
COMMERCIAL:
(commencingwiNSenion]11001of Division3ofthe Businessand Professions Code) or
c C
ern
==not
O
Nat he is exempt therefrom and the basis far Nex
e alleged emption. Any violation of
Section 7031.5 by any applicantfor a permit subjects the applicant to a civil penalty of
more than Eve hundred dollars ($500).
F1 as owner of the progeny, or ney employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (See.]044, Rosiness
❑NEW BLDG/ADDITION DEMOLITION
[]TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
iand
Professions Code: The Contractor's License Law Jas not apply to an owner of
property who builds or improves theater, and who docs such work himself or through
OUTLETS -SWITCHES -FIXTURES
his own employees, provided that such improvements are not intended or offered for
NEW RESIDENTIAL ELECTR SQ pT.
I, SQLL F\T. FLOOR AREA
N ay R
$/SQ. PT.
sale. If. however the building or improvement is sold within one yearofeempletion,the
owner builder will have the burden of proving Nat he did not build at improve for Pur
pox of sale.).
❑has owner of the pmperty, am exclusively contracting with licensed contractors m
construct the project (Sec. 7044. Business and Professions Code:) The Conrantora 1.1.
��
251996
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T
terse Law does natapply manownct-mcaperty who buildsor Improves Neaeon, cad
QTY. PLUMBING PERMIT FEE
who contracts for such projects with a contraclods) licensed pursuant to the Contruemrs
PERMITISSUANCE "r
License Law.
❑ I . inecapa matc,Sri. ,BanPCfor thisreason
{ Vf UUrt'Hi1N0
Dam
ALTER - DRAIN &VENT -WATER RA)
VALUATION
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following deli maim s:
BACK FLOW PROTECT DEVICEIY—
®Owner
DRAINS- FLOOR, ROOF, AREA, COND.
❑ Ihaveand will maintainaCeriGcammComentt, self-rourefar. Worker's ComPen'
•mon, as provided for by Section 37M of the Labor Code, for the Perfmmana of the
STORIES
PE CONSTRUCTION
FIXTURES - PER TRAP
wkI for which Nis permit is issued.
have and will mainmin Worker's Compensation Inntr race, us tenanted by Section
-
Y`
3700 critic Labor Code, for the performance of the work fqm permit is issued.
GAS- EA. SYSTEM- I INC. 4 OUTLETS
OCCGROUP
APN
ywhheic�heytqh�i's
My Work' o pense alnsur nee tamer and policy .118 .rii'TY �g{�
Carrier:�—Policy Ne: 3f Y"1 l
GAS - PA.SYSTCM SYSTEM -OVER
OR
CERTIFICATI..O E%EMPDON FROM WORKERS'
COMPENSATION INSURANCE
(This section need odCompleted Rulednthe Pentair is for one hundusl dollars (1100)
or less)
GREASIVINDUSTRI. WASTE INTERCEPTOR
BUILDI 'DIVISION FEES
GREASE TRAP
PLANCHECK O
z z
y
I certify that in the Performance ofthe work for which this permit is issued, l shall
become subject the Worker' Compen.
not employ any person in any mourner so as m u
fimion Laws of California. Date
Applicant
SEWER -SANITARY -STORM EA. 300 FT.
ENERGY F
NLECTR
WATER HEATER WNET/E
GRADING N E
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
become subject to the Workds Compensation of the Labor Code, must
WATER SYSTWUREATING
SOILS F
a,
D.1
d Q
LJ 0
i✓
U
provisions you
f,Mwidt comply with such provisions or Nis permit shall he deemed revoked.
CONSTRUCTION LENDINGnGENCY
k for by which tat that isaco (See. 3097, Cis, agency for the Performance
the work for which this permit is issued (Sec. 309], Civ. CJ
Lender's Nurse
WATER SERVICE
PAI
aal Receiptp
NEW RESIDENTIAL PLMB. SQ. FC
TOTAL:
Lender's Andress'Tty
a1
BUILDING F `1
certify that 1 have read this application and nuts that the above inforn ion is
N
LJ'4
correct. I agree to comply with all city an d' y ordinances send nam laws relating m
building conxrnnion. unJherehyauNo rep untmivcs of this city mentor up nthe
QTY. MECHANICAL PERMIT FEE
SHISMICFE
PERMIT ISSUANCE
ELECTRIC .E
abovememioned propeny""ins pu us.
(We) agme m save in and p harmless the City of Criterion again.
ALTER OR ADD TO MECH.
PLUMBING E
liabdities,judgments s ch may in any wityummeagainst said City
in consequence of l e it.
AIR HANDLING UNIT(TO Ig000CFM)
MF.CHANI AL FEE
APPLICANT ILL COMPLY WIJH ALL NON
SOBER l _
AIR HANDLING UNIT (OVER 10,000 CFM)
r•ntvcran nnN Tnz
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_
C/ Y-FIAZARUDUS MATERIALS DISCL2)SURE
Will she applicant or future building occupant store or handle harvdous material
as defined by are Cupertino Municipal Code, Chapter 9J2, and the Health and Safety
Code. Sermon 25532(0)?
❑Yes Fl No
I- Will the applicant or future ae building ache [t use equipment or devices which
Ditit havrdous air containments 0s defined by the Bay Arca Air Quality Management
District?
❑Yes No
!quire qtr
I have read the hamrdous materials is under Cha 6.95 of are Cali-
forma Health & Safety Code. eations 35hot i is my and 255]4.1 to demand Out if the
builoting alas not currently have a mramr Nat it is my rezgmsibility to notify are acugom
of the requirements which matt he ma prion, issuance of a Cerriftcam of Occupancy.
u""V
HOUSING ITIGATION frIiB
HEATING UNIT( OI00,0(.JBV)
C
HEATING UNIT (OVER 100.000 BTU)
PAID
Date eceiPtp
VENTILATION PAN (SINGLE RESID)
BOILER -COMP (JHP OR 1 W,OW BTU)
TOTAL
BOILER -COMP (OVER Iboom BTU)
NJ
AIR CONDITIONER
ISSUANCE DATE
ISSUED BY:
NEW RESIDENTIAL. MECH. SQ. FT.
TOTAL:
Owner m i athorimd agent Date
OFFICE