S 2717 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI'T'Y OF CUPERTINO BUB.o1Nc-ELECTRICAL PHRMII NO.
BUILDING:DIVISION APPLICATION/PERMIT PLUMnINC-MECHANICAL (a 7'1 7
BUILDING PROJECT IDENTIF'IC'ATION O 1 1 1
BUILDLNGADDRESS: SANITARY NO. APYLICAI]ON SEEMI'ITAL EASE
76_�`D Still
OWy'�rNA E: '�� ( PHONE: CON' OR'SN Is / hIC �O CON
O � ��
9
� �C. � 2SZ" �GZ yyy N&JRD�.,F,.(.x�//�� 2�10J,') NIC C(1N'I'HOLp
ARCIIITECDENGIN[EB: LIC NO: sz, to 'rW Pv \I7 Ifs` / ❑
CONTACT NIONE: BUILDING PERMIT'INFO
❑ Consultant Fees paid by Applicant(Initial) HLDG ELLEECCP/(PLUMB MECH
LICENSHID CONI'RACE OR;S DECLARATION Q'{-Y ELECTRIC PERMIT FEE
I hereby amino that 1 atm Recused made,pnwilue,of Chahar o Kommencing JOB DESCRIPTION
DWZ withSection WXllB of Division 3 of the Business and Professions Cole.an mylicen,e i, a�� RFSIDENTIAI:
ad o PERMD'ISSUANCE
QUO Licensfmr la.,snd clGla b Lich ❑SFUWL ❑KI'I'CHF.NREMODHI,
, U Co me
APPLIANCES-RI!SIDI?N'I'IAI. ❑ADOI'IION ❑PLUMBING BE PIPE
It W Uatc
,RCIID'ECPSDECLARATION ❑NIULTI-UNIT ❑STRUCfURAI.
F-Z I understand myplamshall he used Io public records PANELS h10DIFICA'110N
Z07041_Q UPT02S)AMPS �l� ❑INTERIOR ❑CIIIMNEY REPAIR
F�F"W Licensed Professional 201-ItNX)AMPS IMPROVEMENT EjSWIMMING POOLS
K C 1 hereby affirm
OWNER-BUILDERI um exempGnlm the DECLARATION
ois License law for the OVER 1000AMPS ❑BATH RF:MODEL/REPAIR ❑DEMOLITION
{y�a
U fMuwingteaxon,(Suction 903t5.Hu,ine,,lmal PufcAinna Code,Any ell,Or county .SIGNS iI.EC'I RICAL ❑(YI'HEN
W'3 LL-E1 which ngaims a peruid In eonstmel.roles'Improve.demolish.m repab any stmcom -
IE:OQ prior to its issuance.also requites thcapplicanr for such pennitto tilca,igned,on—t'nt SPCCIALCIRCUIOMISC.
E2} Ihath sl dp ti Ih p fth C I I .I I (Chapter COMMERCIAL'.'.
W 0 (c(nuourneing III Seel on9(XX))ofI)' '.' 3 f he Bu,mm,it III t .." :Code)... ILM P.MI1-fERORPO1.EINS'1'.
m d e C That he is exec pI therelrour and the ha:.for the alleged esu.npI ca A y violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W^h Seninn'/031.5 by any applicant for a permit subject.the applicant to a civil penalty of POWER DIiVICES ❑'DiNANT ❑I'OOU SERVICE
not more than five hundred dollars 155U0). IMPROVEMENT
FyQ ] I,as owner of the pm tFyym I^y untpinyccs wish wngv, ,thein..)..compensation. SWIMMING POOL 1:LECTRIG
�F.o reit)do rhe work.—Olnevtnmmre us nnl intended or offered for sale(Sec.9194,H..incss E]GTE
a�eo and Professions Code:The ComtiueaKs Lierme Law doe%not apply to an owner of OUTLETS-SWITCII ES-FI%TURES
property who build.,or improve,thereon,and who does such work himself sur through
hi,own cnrplmyces,provided that such improvements arc n i intended ,r nRcred fns NEW RBSIIIF,NTIAI,11LECI R SG IT.
,ale ll:howevcmthe buildingor'unprovemenrissold within one year ofcmniletion.the SQ IrI'.IT,OOHANEA 5/SQ.I'1'.
owner-builder will have the harden of proving that he did not build or improve for pur-
1 po'cofsalc.). 'IDAL O
❑ I,:u mwac,uI Ihc p,;,�ny am exclnshely commedng with licau.cd cnmractm,w a
au,muct the tm)cct(See 7044,Business and Prnfe,nion,Codc:)'me Cbmimcnrt,LI-
seLaw does notapp,to on uwncr.R pro,my who mildsmr improve,thereon,and QTY. I'LUNIBING PERMIT FEE
who contracts for such projects with a contractions)licensed pursuant o the Contractor's
Lice—Law. VERNE I'ISSUANCE
I lam cxettl under See ,B&P C lir this,caw
ALTER-DRAIN&VENT-WATER(EA) VALUATION
At
Owner Dae
1- WORKER'S COMI'ENSAFION DECLARA'I'[ON HACK FLOW PRO]ECL DEVICE
I hereby off rad under Efmahy of per]ury one of Ihc following declannimrs
❑I have and will maintain a Cenificam of Consent an,elf-insure for Worker's Cori DRAINS-FLOOR,ROOF.AREA,COND. SII TYPE CONS"I'RUCTION
ration,u provided for by Section 3900 of the Labor Cola,for the performance of the t
for which Ibis permit is issued. FIKTURES-PER'TRAI'
have mal will romotain Worker',Compematiou Insurance,us reputed he Sadden pp��//II
I of the Latae Code,for the performmnec of the work for which mix permit a issued. GAS-F,A,SYSTEM-I INC.4 OUTLETS IYIY 0. P Ii AI'N
My Works' Trop y '`p f" d Policyyyy qquupp����� �X�
Carricl-. Policy NnC fRzk / GAS-F:A.SYSTIiM"OVER4 DiA1
GL'RTIPI�I'1UN FROM WORKERS' GREASEANDUSHU.WASTE N'TERCEPIOR
COMPENSATIONINSURANCE _ BUILDINGI VISIONFELS _
(This Lcclian need nutMttimpinCU iOhc permit is(..made M1uadrcU Jnllam(SIIX)) GREASE.TRAP
WPAID
..r less.)
thad kc...ne ;met to petmil rker,CmanK.- SEWIiH-SANIIAHY-SIDNM FA.2q)PI'.
not employ any tenon in any manner m a,m hccnnm subjcm m the Workers'Compen- ENERGY
Z .motion Iaw,of California.Dam WATER HEATER W/VCNTd?LELTR
zQ Applicml
h NOTICE TO APPLICANT:IL after ntaking this Cenlfcate of Exemption.yon should WATER SYSTEM/TREATING
become subject ai the Worker's Compensation provisions of the Labor Code,you nmsr
W. fnnhwilh comply with such provioomnrthis permit shall be deemed revoked. WATER SERVICE
Q CONSTRUCTION LENDING AGENCY NEW IIESIUEN'I(At,PLMB. SQ.PEptk
U0Ihembyaf enflum there,,a commcdor letdo,itgency for the performance of
the work for which this permit is issued lSce,10G,Civ.C.) 'H)TAI.:
ULender's Nano
1., Sets Address 'IO'IAL:
} d I cenily that l have read this application and state that the above intormmion is BUILDING FE
F y correct.I agree or comply with all city and county ordinances and state laws morins to QTY. MECHANICAL PI?RMIT FEE SEISMIC FEE
V Z huildingcorunclion,and hereby autho,irerepresenratives of this city meaner uprm the
above-mumti—M podwrty for impmrion purponcx. I'ENh11'I'ISSUANCE ELECTRIC Il
(We)agree Ire save,indemnify and keep harmless the City of Criterion against
Iiabiliticcjudgment.a,costs and expenses which may in any way acemc against said City ALTERORADDTOMECH, PLUMBING FEB
in vunw,reme of the&earring of this pencil.
APPLICAN'I'ENDERS I'ANDS ANI)WILL COI I'S.Y WI'III ALL NON-POINT' AIR HANDLING UNI'I'(SO BLOSSOM) MECHANICAL FEE
SOUR(
AIR HANDLING UNIT(OVER 10,000 CFM) CONS I'RUM IONTAX
Slgnammo ppbeanJC-nnl me ter vie I!XHAU5'I'HOOD(WIDUCI7 I IOUSINGMRIGAT1ON1EE
HA].ARDOUSMAI'IiRIAISDISCLOSU -
WilI the appluerm or future building occupanl'to,nee or handle Sharman.,mammal ISEATING UNIT IT 0 IBU.IIW H TU)
a,defined by IM1c Cnpenlnn Municipal Code.Chapter 9.12,:0.W the Ile,ph and Safety
Code,SCetion 25532(ujs IIIiATING UNIT()VEI<IW.IX11111'1'11)
0 ye, Is
VENTILATION FAN(SINGLE BESIDE PAID
Doc Receipt#
WII lbs apphr.ur rt'umm buildia —etipmet use cyoitmeat adevwe,which HDILI!R-COMP(311P OR IlN),tlfN)NTII)
•snit h,omoon,air ermuntinnmrs as dethred by Ihc {ay Area Ar Quuliry Mamlgcnmol Tl AL:
DismieRBOILER-COMP(OV LIR[00.000BTU)
I]ye, X5a'n
I 'IJ that Iain):'9 Lends <I pal f)5 ofthcCul. AIRCONDI'fIONER ISSUANCE DAPI:
I
Surma nealm&S,Evy C sl Scefinus 25505 2550.add 255E I rebound that if the NEW RESIDENTIAL ME-CH. SQ.FT.
buildingdoes notromentlythascalenant.that):toy mspmxibltyt ifyrheceeupml �/
off'Ihc my -r i 4lm mct ,ounce nfu CCnifcatcn (kalp: I
� p
Owner acoa cut TOTAL: ISSUES)BY:
OFFICE