24537 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOIL RI L. AL PER 411 NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL /I C �J
BUILDING PROJECT IDENTIFICATION 4 J r
BUILDING ADDRESS: SANITARY NO. APPIJCATIONSUBMETTALDATIi
UNIT# LOT#
OWN' SNA .1 S3 PHONE CO AyrORS NAME: LIC NO:
NIC CONTROL#
ARCHITF.CfgiNGINEER: + hIC NO: ADDRESS:
CONTACT: PHONE:
QTY. ELECTRIC PERMIT PEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RFSIDENI'IAL JOB DESCRIPTION
n=z I hereby affirm that l amlicensed underpmvisionsofChapter9(commencingwith
WOWO Section 7")of Divisil feon 3ofthe Bminst, it Professions Cole,and my licenseb cur PANELS if � � ��
t6U� fulorce rane t. /
Z I.iClass � OLic.# S A UP T02W AMPS f✓Tb✓
NyZ ..at I ARCHITECTS DEC ` TION p . 201-TWO AMPS SQ.FT.F AREA $/SQ.FT.
ZO Z-C) I understand my plans shall be used as public records. OVER IOW AMPS 31ya
P:Vl1-W SIGNS ELECTRICAL Y
a d-� Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC. �j i• �; 00
Owl`
I hereby effum Nat 1 am exempt from the Comments License Taw for the
W 3 a y following reason.(Section]031.5,Business and Professions Code:Any city or county TEMP.ME E-R OR POLE NST. - ^ tt '
tvi which respires¢permit to commic,alter,improve.demolish,or.,i,any swcture Try`Vy
M}M£ prior to its issuance,also requires the applicant for such permino flea signed statement POWER DEVICES
0 tcensepursuant the Provisions of the Contri License Low(Chapter
a<0 he is lid hisi
d 0� 9(commrnciagwith Swell.n9000).f Division 3ofthe Business and Professions Cole) SWIMMING POOL ELECTRIC VALUATb
.,that he is exempnherefrom and thehasis fndn,allegexl exemption.Any violation.( �96
�zQ Section 7031.5 by avy epplic.t fears .it.bj.eN the¢pplieenuo¢civil penult,of OUTLETS-SWITCHES-FIXTURES
C not mare Nan five hundred dollars,($500). [CIR .
[n�11 0�0 ❑ I,mowmrofNepmpe y.ormyemployeuwithwarsmtheirsolecompemNEW RESIDENTIAL I?LSQ Ff.
¢tion, STORIES TYPECONSTRUCTION
o. willdo the work,and the structure isnot intended oroffered forate(Sec.?044,Business
and Profession Code:The Comments,',License law dues not apply t.an owner of
protea,whobuilds orimprovesthetmn,andwhod.nsuch work himself.rthrough his
empl.yees,providd NauuchimprovementsxrenotimrndeJ moffcrcd fors¢Ie.IL OCC.GROUP RES.UNITS
however,the building or improvement is sold whin one year ofcompletion,the owner- TOTAL:
builds will have the burden of proving that he did not build or improve for purpose.(
sale')' toraut QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ Lm project(Sec.
70P4,Business
usinesvel it pronasionng s mlai)sedconnmbure,
Licens n the wdisamr(Sec.9044,Ousinese and A.fessi.ld Code)The Catamcmrs PERMIT ISSUANCE 5 0
Licensetrawdfr such ppjects owncrofpropertywhosedpursumprovee rhere.aoes
Lienee contracts for suchpmlectswith ewnvacmr(')licensed pursuant to Commctor's ALTER-DRAIN&VENT-WATER(HA) FEESUMMARY
License law.
❑ 1 an exempt under Sec. B&P C for this reason BACK PLOW PROTECT.DEVICE OUTSIDE FE
SANITARY Y N
Owner Dam E IPI
• WORKMAN COMPENSATION DECLARATION DRAINS-F100R,ROOF,AREA, CH — N
❑ Thereby effitm thetlhuve ncenificme of cnnsann selM1insurc,ora ccnificam of FlXTURES-PER TRAP EIPf
Workers'Compmationlnsumnee.racenifiedcoythemof(Sec.38W,Lab CJwhiah SpA KPES N
I� �t �I EIPT#
covers assents Nis pe it GAS-[iA.SYSTEMd INC.4 OUTLETS BU tBIN D ISION FEES
Y {..�y.�9yJ_
Company- .8 � GAS-EA,SYSTEM OVER
4(EA) A
❑ Cende yrs hereby umtshed
CedifiWenpy it filedwiN thecityinspeniondivision. GREASE/INDUSTRL WASTE INTERCE I GRADING
CERTIFICATE OF EXEMPTION FROM WORKERS' GRCASE'FRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not he completed ifthe permit is for one hundred dollars(SIM) SEWER-SANITARY-STORM EA.21MFT. ENERGY FEE
or less.) _
I certifythat is Ne perforartmeof Ne work for wbitlidds permit is is.d,Ishan / WATER HEATER W[VENT/F:LECTR O
not employ any person in any manner so as in become subject to the Workers' a S PAID
Compensatioal.awsof C¢lifonia. Date WATER SYSTEMGMEATING Data Receipt
Q of Exemption,this Ce
O NTO APPLICANT:I
Applicant OTICE Lafler making ni6ate ti
p or',you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
Iz. FA become subject to the Worker's Compen.don provisions of Ne Labor Code,you must
1a^ forthwith comply with such provisions or this permit shall be deemd revoked. BUILDING FRE
W Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby effna that them is a construction lending agency fur the Performance of
O TOTAL: ELECTRIC FEE
the work for which this permit is issued(Sec.3099,Civ.C.)
Lender's Name
0 , Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U1 certify that 1 have read this application and slide that the above information is MECHANICAL FEE
0. counsel. l agree to comply with all city and county ordinances and state laws relating to PCRMIT ISSUANCE
y building construction,and hereby euNorins representatives of this city to enter upon the CONSTRUCTION TAX
U Z above-mentioned property for inspection purposes. ALTERORADDTOMECIL
(We)agree m save,idemaify and keep harmless the City of Criterion against
Iiubilities,jidgmema,cons and expensuwhich may ia.y vayucnteugainstat id City AIR HANDLING UNIT(TO 10,000 CFM)
onse,rence of the granting o his mat.
AIR HANDLING UNIT(OVER 10,000 CFM)
tgnamm of Applicant/Conuacmr Date EXHAUST HOED(W/DU7G
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 B-I U) Dam Receipt#
Will the applicant or forum building occup.t stere or handle hazardous material HEATING UNIT(OVER 100,000 BTU) TOTAL: ,4-0
as defind by Ne Capsules,Municipal Code,Chapter 9.12,and Ne Health and Safety
Cala Senior 25532(e)?
1)Yes ❑No VENTILATION PAN(SINGLE RESID)
"BTU) P I�AATV DATE
Will Neeppliranmrfuntrcbuildingoccupnnt uueyuipmemordeviceawhich emit BOILER-COMP(JHP OR IM.
barandm air ommunrin.ts.defined by the Bay Arco Air Quality Management BOILER-COMP(OVER IM'"BTU)
Dislricl?
❑Yea ❑No NEW RESIDENTIAL MECH. SQ.FT. 18 1993
I haveread the hazardous materials mstuimments under Chapter 6.95 of the FEBV v
California Health&Safety Code,Section 25505,25533 and 25534. 1 understand that /al �I- �ak1T'Gf1111VV
if[be building does not currently have a tenant,that it is my responsibility to notify the V
occupant of the requirements which must be met prior m issuance of o Certificate of
Occupancy.
Owner or a¢thorized agent Date TOTAL: ISSUED BY:
OFFICE