S 0734 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILIING-EL.F.C'TRICAL IIIS41'r NO. O 4
BUILDINGDIVISION APPIACATION/PBRMIT PLUMBING-MECHANICAL J
BUILDING PROJECT IDENTIFICATION
BUIL IN D P S ) SANI'T'ARY NO,
APPLICATION SUHMITTAL DATE
l r�Cc n-v �� fir°/ 12-
0 �z�7
W)ffJt:S�{AM .�f� 10NE � RACI'OR'S NAME: LIC NO.
// / /y NIC CONI'ROLK
• ARCHITECT)ENGINEER: f, LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT PIS
I hereby affirm that 1 am licensed under pmvisions of Chapter 9(commencing JOB DESCRIPTION
MZZ with Section of Division 3 of the Business and Profcssinna Code,and my license is RESIDENTIAL:
W p O PI?RM IT ISSUANCE
F W2 in full force and effect. D SFDWI, D KITCHEN RL?MODEL
(-.zEkJ Licenu Class Lic.p APPLIANCES-REST OI3NTIA1. DADDITTDN ❑PLUMBING RE-PIPE
"IZLsl Dme Connector
Fly ARCHITECTS DECLARATION PANELS
T ondermhol my plans shall ❑MULTI-UNIT' D$TRULTURAL
Z p pJ Z heused as public records MODIFICATION
OZ UP B'02W AMPS INTERIOR El CHIMNEY REPAIR
4^�EgqW Licensed Professional 201-1000AMPS IMPROVEMENT r:1 SWIMMING POOLS
�yyj OWNER-BUILDER DECLARATION OVER 1000 AMEX D BATH REMOD171JREPAIR ElDEMOLITION
d'66�''Q I hereby affirm that I am exempt from the Commam's License law for the
iqqi55 L U following reason.(Section 7031.5,Business and Professions Code:Any city or County SIGNS ELECTRICAL DO'THER
fu 3 V-N which requires a permit to construct,alter,improve,demolish,or repair any much re .5G-
0 pdarm its issuance,also requires fltapplicatnforsuch perrat mfileasignedsmm
tecat SPECIAL CIRCUIT/MISC.
that he is licensed pureuantto the provisions offer,Conoweloes license law(Chapmr9
fa OQC (commencingwiNSection 7g10)efUivisianl nfthe Nosiness and PmfasionsCWe)ar TEMP.METEROR POLEINST. COMMERCIAL:
a z that he is exempt therefrom and the basis for the alleged nemption.Any violation of D NEW BLDG/ADDITION C3 DEMOLITION
LL• S applicant LOWER 7031.5 by any applicant for a permit suhjmts the applicano a civil penalty of WER DEVICES []TENANT ❑FOOD SERVICE
Spm more Than five hundred dollars(8500).
I,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL CLECTRIG IMPROVEMENT
F- willdothe work,andthe structure isnot intendedoroffemdfor sait,—.0014.Business []OTHERW and Professions Cade:The Contractors License Law does not apply to an meet of OUTLETS-SWITCFlES-FIXTURB
6 3^ propmy who builds or improves thereon,and who does such work himself or through
his awn employees.provided that such improvements are not intended or offered fm NEW RESIDENTIAL ELECTR SQ
.1c.if,however,fhe building or improvement is sold within on year of completion,the SQ.PT.FLOOR AREA g/SQ,FT.
owner-builder will have the burden of proving that W did not build or improve for fam,
pest of sale.). CEIVED
❑I,as owner of the progeny,am Business
and confessions with )The Ccanwcvm i-
ase athees not
(Sec. rope Professions Cade:)Tho Contesaon. nd
cense Law dcesnm epplY to an owner of property who builds or improvevhereen.and QTY PLUMBING PIiRMIT �F.
whocammctsforsuchpmj rewithacontmcmro'UmonsWpursaummtheCommctors DEC 121997
License law. PERMITISSUANCE
Dlam and .B&PC for tis tesun
et ALTER-DRAIN&VENT-WATEll(EA) Y: VALUATION
Owner Date 1
WORNER110IIIAPENSA3'ION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby.flares under perolu,of perjury one of the following declazafiom:
D l have and will maintain aCerificumof Conscntmself-insure for Workers Compen- DRAINS-FLOOR.ROOT'.AREA,CONED, STORIES 'TYPE.CONSTRUCTION
sation,as provided for by Section 37M of the UNIT Cade,for the performance of the
work for which this penrdt is issued. FIXTURES-PER TRAP
D 1 have and will maintain Workers Compensation Insurance,as required by Section
37M of the labor Code,forth,perfmmanceof the work far which this permit is issued. GAS-FA.SYSTP.M-I INC.4 OUT LETS OCC.GROUP APN
My Workds Compenmtion Insurance carrier and Policy number are:
Carrie,. Policy No: GAS-P.A.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASUINDUSTRI.WASTE INTIiRCEPD)R
COMPENSATION INSURANCE BUILDING DIVISION FE
(Tussection need not hecomplefed iftha permit is forone hundred dollars($100) GREASETRAI'
nr Ins) 1'IANCIIBCK Igili
Immify that inthe performancentric work for which this .it is issued,l shall SEWER-SANITARY-SIORM IIA.200 IT.
not employ any person in any manner so as to became subject to the Worker'Compen- IiN1ikCY FET?
job
ZZ stairs laws of California.Date WATER THAfER W/VHNT/BLBCTN
0 Applicant ' GRADING FEB
yNOTICE TO APPLICANT.IL alter making this Certificate of Exemption,you should WATER SYSTEM/TREATING SOILS IIiE
a ? became subject to the Workers Compensation pmvisions of the Labor GvJe,you muss
LiI fanhwith comply with such provisions onhis permit shell he seemed revoked. WATER SERVICE
') Q CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMR. SQ.]IT. PAID
Z Iherebyaffimt that there iso consaucu.lending agency for the perfomranccof Dam eeiptN
U 0 the work for which this Permit is issued(Sec.3690,Co.CJ
O U Lenders Name TOTAL:
TOTAL'
Lender's Address
LtiT I cenify that I have read this appliciumn and state that the above information is BU1LDI NG FEE
s�Ty crown.I agree to comply win all City and county ordinances and state laws relating to QTY. MF.CHANICAI,PERMIT ITE
U Z building construction,and hereby authorize representatives of this city to trier upon The SEISMIC PEE
above-mentioned property for inspection putTuses. ]'To R M IT ISSUANCE
(We)agree m save,indemnify, and keep harmless the City of Criterion against Ii1.GCl'HIC ITC
Liabilities,judgments,costs and expenses which may in tarry way accrue against said City ALI'ERORADDIT)MliCll.
PLUMBING FEE
in consequence of the counting of This permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIN HANDLING UNLT f010,opp CEM)
MECHANICAL PGIi
SOURCE REGULATIONS.
AIN HANDLING UNIT'(OVER IO,(XXI CVM) I CONSTRUCTION TAX
Signature of Ap,fcanUCrmrwmr Data EXIIAUSTHOOD(W/DUCT') HOUSING MITIGATION IEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle Woodnus material HEA'T'ING UNIT('T01(k),000 BTU)
us dented by the Cartoon Municipal Code,Chapter 9.12,anti the health and Sarety
Cade,Section 25532(a)7 11 IEAI'INC UNIT'(OVEN 100,(0)141'111
E]Yes C]No V EMT[LAT PAN(SING LIi RES I D) PAID
Date Receipt N
WIII the applicant or future M1ulldin6 sc<vpom um equipment or devices which• BOILER-COMI'(J11P OR 100.0)0 BTU)colt brood...air connotations,a,defined by the Bay Area Air Quality Management TOT'
Disricil BOILER-COME(OVER 100.000111 U)
E]Yes F1No,
1 have rood the hoznNouv materials mquiremenin untla Chvpmr 6.95 of the Cut I.
AT It CON DITIONER ISSUANCEH
Tomos Health&Safety Code,Sections 25505,25533 and 25534.1 understand That If the NEW RESIDENT Al.MSCI I. SQ.FT. / /�f --1,
building does not currently have a tcturs,that it is my reslrnsihilhy m notify the occupant ( L�
of the requirement,which list Turner prior to Issuance ofa Cerificae III Oe malt,
Owner or authorized agent Date
TOTAL 1SSI11iD If Y: C,(%1 "[f YVl lJin
OFFICE