25506 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
APPLICATION/PERMIT PLUMBINGMECHANICAL. n C ['O C
BUILDING DIVISION BUILDING PROJECT'mENTIF'IGA'I'ION G J J v
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
LNITX LOT
OWNIi11SN M13: PHONE:
7 dd' .
VI NAC CONTROL#�� Pl�
ItCl IDI A GINHE : LICNO: ADDRESS: El
CONTACT: PHONE:
QTY. ELECTRIC PERMIT Ff?H BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
FERMI'I ISSUANCE Ar ❑ 0
LICENSED CONTRACTOR'5 DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
galz Imacbyaffimm that Ism licensed unchmprovisions of Chepter9(commencingwith
WOO Section 7000)of Division 3 of the Business and Pmfessiom Code,and my license is in PANELS 1
Eft�j F full farce effect,
zau� License Camlas s Lic.p UPT020B AMPS
i,a<y Data Contractor 201 1000 AMPS
Z Oyz ARCHITECTS DECLARATION OVER TWO AMPS SQ.FT.FLOORARG $JSQ.PI'.
Oz
^ I understand my plans shall be used as public records.
F N i ty SIGNS ELECTRICAL
yd] Licensed lkofessinnel
� OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
W U I hereby affirm that 1 am exempt from me Contractor's License Law for the
tcl3ylm¢"' followingmsxnn.(Semion 7031.5,Business and Professions Coda Any city or county TEM 11.METER OR MIX INST.
C�wJ which rcyuimsu permit conswct,alter,improve.demolish,.,repair any structure
at r^Y� r to its issuance,also the applicant for such Uo rile asined statement POWER DEVICES
prat quires pp permi g
� ¢p
that misnlicensed
with
Socm,7")of provisionsofthe the Brains LicensenProteaw(Chapts)
y o�' 9(rommcncing wim Section7W0)of Divisinn3.f rube Business and Professions Code) SWIM1IMING POOL ELECTRIC VALUATION
—y or that he is exempt herefrom and the huisfor the alleged exemption.Any violation of A t
�zQ Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES
am are than five hundred dollars($500).K NEW RISIDFMIAL ELECIR _SQ,FT.0 ❑ I.unwnerofthepmpny,mmyemploymswimwagesutheirsolec=Nmvon, STORIES TYPECONSTRUCTION
y3— win do the work,mcimmormarre isnot immriddoroffmad fo,wle(Sm 7044.Rumors,
and Nofaasions Cody.The Conmmor s License Low does not apply to sn owner of I
property who buildsmimprovesthereon.and whorl.such..,it himselfindamugb his II L , s I ^C GROUP iI RFS.UNITS
oxmcmpinyees.providel thatruch improvements arenotimeadeduroferd forsale.If, ` \
however,the building orimprovement is sold within one yearofcompldon,the owner- I,1
builder will have the burden of proving that be did not build or improve for purpose of l'Ol'AL: 1 -� `� I�
1e' QTY. PLUMBING PERMIT FEE Il F D E APN
I,as ownerofthe property,amexclusively contracting with Iicenseneonwemrs m 1,
con rust the project(Sec.7044,Business end Professions Code)The Cnntm um's
Lice a Lawdoes not apply man ownerofprnpeny wh.builds.r improves merson,and PERMITISSUANCE
whoconvacis forsueh projects wimacontractor(s)licensed pursuant o the Contractor's
License Law. AUTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 um exempt under Sm. .B&P C for this reason BACK FLOW PROTECT.DEVICE SANITARY V D'N
Owner Dam RECIi1PT p
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Iherobyafhad that l haveacenificateofconsenttoselGinsure,oracenificate.fFLX•LURIS-PER TRAP RECOPTp
'Workers'Compensation Insurance oreunifid copy mercof(Sec.3800,Lab CJwhich PARK F'EE YN
overs all employee's under this permit GAS"P.A.SYSTEM-1 INC. OUTLETS RECIEPT N
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTPN-OVER 4 LEA) PLANCHECK FEE.
❑ Ceniriul copy ie hereby fvmishd.
❑ CenilieJ copy is fled with the city impaction Division. GREASPONDUSTRL WASTE INTERCEPTOR GRADING Flip,
CURL IFICATE OF EXEMPTION MOM WORKERS' GRBASETRAP SOILS FEE
COMPENSATION INSURANCE
(This sectionnced not be completed ifthe permit is forone hundred dollars($100) SEWER-SANITARY-STORM EA.200T. ENERGY FHL:
or less.)
Icertify that in the performance ofthe work for which this Permit is issued.l shall WAT17R I IPA'rER W/VEN9'/ELECIR
not employ any person in any manner so as to become subject to the WorkersPAID
Compemationlswsof Califomia. Date WATERSYSTEM/TREATING Date Receipt#
O z Applicant
Z 0 NOP'ICF.TO APPLICANT.If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TO L:
r r� becomesubjectto Wode/s CompemaG.n isiomofthe Isom Cde, .0 must
forthwith comply With such provisions or this Permit shell be dttmd resulted. BUILDING TEE
a Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z Iherebyaffiromat,here is.construction leadingagency for the performance of
IJ O the work for which this Permit is issued(Sm.3097.Civ.CJ TOTAL: ELECTRIC FEE
I•ka rr Lcralms Name
O U Isndcr's Addrcxs QTY, MSCI IANICAL PERMIT IEE PLUMBING FEE
U I cenil'y that I have read this applicati.n and e[ate that the nlnwe information is
corer. [agree hicomply with all city and county ordinances andstate laws relating to PERMITISSUANCE MECHANICAL PER
mildingconswaiest harcbysmhodm representatives.finis city to enteruponthe CONSTRUCTIONTAX
V z move-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
w. (We)agree m save,indemnify and kap harmless the City of Criterion against
Iimilitiesjudgmems.costs andexpeuses which may in any way accrue against said City AIR HANDLING UNIT(TO Iff"CFM)
i veare of ine'tenting of this
AIR HANDLING UNIT(OVER 10.000 CFM)
Sign. n Applicam/Contmctor Date EXHAUST HOOD(W/DUCT) PAD
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,00)BTU) Date Receipt#
Will the applicant or furore building occupant store or handle munitions material BEATING UNIT(OVER 100,000 BTU) TOTAL:
us d,ri,d by the Cupenino Municipal Code.Chapter 9.12,and the Health and Salary
Cdc,Seefmn 25532(n)7
CI Yes ❑No VENTILATION PAN(SINGLE RES#)
es
Will the ucontainants.re building occupantay Am Air
Quality
Manageemit
BOILER-COME(311P OR 10LLS10 RTU) ISSUANCE DATE
Disnrdom air contaminants as defined by me Buy Arco Air Quality Munagemem BOILER-COMP(OVER 100,000 BTU)
District?
❑Yas ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have ted the haamdom materials requirements under Chapter 6.95 of the
California Health&Safety Cde,Smtions 25505.25533 and 25534. 1 understand that
if the building dos not currently have amount that it is my responsibility to notify the Int A
occupant of the requirements which must he met prior to issuance of a Certificate of U� 404
Om.pancy.
Owner or authorized!agent Data TOTAL: ISSUED BY:
OFFICE
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