00040096 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALLPOINT PEN ONLY
CITY OF CUPF.RTINO BUILDING-EIECHAICA O^ / rT:R Ir Np+ D.
BUILDING DIVISION APPLICATION/PERMIT rLUMBIrvr.-NI?cnnrvIFIC /7JY/✓n ��T7S��
BUILDING PROAU:1'IDF.NL'Ib'ICATION-
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBM1'I'IM.DATE
1 o042 Dc A"z-ok. C31 `�7 7-1
OW ER'S NAME: 11 � PHONE: CONTRAC'TOR'S NAME: LICNO:
�VV.QIZU� NIC CONTROL#
ARCHITECT/PNGINEER: LIC NO: ,S(0b 0. UIM" S�- ❑ / �0�
CONTACT: PHONE: V ��(� 'BUILDING PGRMITINFO
NoAq ,j2O § ❑ consultant Fees Paid by Applicant(Initial) 111.UO EIf,1,1?Cl 'PLUMB MECH
V ❑ ❑
LICENSED CONTRACI ORIS DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm tam 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
O=Z with Secrim'IUXp of Division]of the Business and Professions Cole,and my license is PERMIT'ISSUANCE
W p RESIDENTIAL:
yeFy w r in all funce mut Aber t r l.G�- Liu p T•-1 f-•� ❑SFIJWL ❑KITCHEN REMODEL
Ld.Zp1 Dam 4 l-II G] _10 L'ananc-ioJr l APPLIANCES-RESIDEN,IAT. ❑ADDITION ❑PLUM R I NO R I:PIPE
Nd_y �7 ARC[I I FEC T'S UECLARAT'[ON ❑MUI:U-UNIT ❑STRUC'I URAL
F Z I understand m 1 shall be used as public records PANEL ti MODIFICA'T'ION
zoo my
OZ-0 UPT02aX1AM1'S ❑IN]IERIOR El CHIMNEY REPAIR
a4 E"; Licensed Pmlesilnnal 201-1(XXIAMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER INKAMPS ❑HATH REMODEUREPAIR ❑DEMOLITION
E 6 I hereby affirm that 1 am exempt from the Comm oar's License Law for the
%O�U fodawing reason.(Section 9(D I.5,Buoine,m and Pmfoseions Gala:A.,city.,county SIGNS FI.ECTRICAL ❑Of 11ER
1113 w y which require H Icluld In consumer,ahcr,Inmmve,danmliah,o, epoi,any nrurlure
OCT
prions its issuan,r.dso mquirc,the vppllcrm for such permit to file v signed.gmcmcm SP CIAL CIRCIII'I/MISC.
that he is licensed pursuanuoNeprovinonsofNeConnetor',Licen,,Law(Chapter9
I11W00 (coamenringwhh Section Tim)ofDivi,inn JnOhe Business and 11..I..tons Chi TEM. -TER POLE INS'T, i..., COMMERCIAL:
lL 6 p C that he is esentpu wherefrom mad the basis far the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
LL Section 7031.5 by any applicant for n permit subb, lymplicumm a civil penalty of pO D'VICES
:2 no V []TENANT ❑FOODSERVICE
not more ahan Evc hunJrW doll (ES p' IMPROVEMENT
��d ❑ Lvs owner of lhepro gc,ns rheivsolecnmpeusution, SWIM )OLP, �C C
G willdo Ne wurknnJ e,'�{p1}� trnithndal ar offers far xnlefticv.9044,1iminass O'I'IIHR1 9kQ'SO'41✓
55 m and Professions Ctulohe Inr'x Lir h.ry(af-s nm apply m an nwnn'nl OUTLIi GS-S -FIX'I ARIES GM S �•�p*j']N ��
property who build.vor improves tlf�r in vas,,i . ch work n:mx.... through
his two employees,Trovid cM1 pmvememe arc not intended or ethereal for NEW RRSH 'VITAL E .C!'R SQ EI'.
sale,If,hawevcclhe building bliiRprovensnt is sold within one your of completion,the SQ.FI'-1 06 ARIEA \E/SQ.IT.
owner-builder will have The burden of provingdpW��I(�1n mild or improve far par-
Too, fole.). ,1 m%G
q l I rhe p p ay 1pWl cem a i t b with contract In TOTAL:
coat nh J 'ap to
l JP who :Cul improves
C t m lid - - �
who co t such
applylej ont Try h builds T Contractors o rs QTY' PLIIMHING PIERMIT FE
r.�nm t tr :tent 1 t m emm a rc>r aTa:a tet me .
License Law. PERMITISSUANCE
❑ I um exempt under See ,B&P C for this mama
Owner [)air ALTER-DRAIN&VENT-WATT (E,G N.UAf[ON
• WORKER'S COMPENSATION DECLARATION BACK PLOW PRO]HCT DE/11I
IIImby co rat under penally ni ,,try ane of the following declum rm, 1
I have and will ammain u Certificate of Consent to sell-neon,our Worker's Coopen. DRAINS-FLOOR,ROOF ILEA.COND. STORIES L31
H CONS'IRGCTION
soon,as provided for by Section 3810 of the Labor Cale,for the performance of the
r which this permit is issued. FIXTURES-PER TRAP
w I have and will maintain Workers Compensation Insurance,as requital by Section
JT of the Labor Cole,far the performance of the work for whichthis permit is is.sued, GAS-TEA.SYSTEM-I INC.4 OUI'LITS OCC.GROUT' AI'N
My We Con pe Insumnce currier and Policy n her k
Carrier�gtj �i�d Policy Nn: r�S D���, GAS-HA.SYSI'EM-OVER TIE ) 6�/
CERTIFICATE OFHXEMIrHON FROM WORKIEIt S' (� V
COMPENSATION INSURANCE. GREASE IINDUSTRLWAS HIN'HERCE R
(This section need not a complete)if the Permit is for env hundred dollars S 11X)) BUILDING DIVISION PEES
or less.) GREASE TRAP
I'IANCiiIiCK FEF.
Iti'myN:ninthe performance theus
work for which ltiions Wckes'Coo halt SEWER-SANITARY- '1 IEA.20a FT
led employ any person ma yman t beeyyme objections Workers'Cmnpem ENERGY PI7E
ZZ union Law ttli ii�) i1 rDu WATER IIHAI'ER W/VENT/ FCI'N
App7jpuh - -" k/r- L1a{J.- GRADING FEE
.�.m NOTICE TO APPIACANT.If,ofier making this Cenlfieao it l eat,ion,you should WATER SYSTEMITREATING
a , become subject to the Workee,;Cem,moiaton provisions of the Lubar Cmc,you mum SOILS PER
forthwith comply with such Neoisiomo,this permit shall be deemed revoked. WATER SERVICE
Q
U O CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL ELSE. SQ.FT PAID
I herwhich thi that there issued Xv ion lending agency lot the perfornvn<v of Date RadplN
w F Na wok for which this Temtil is issued(Scrv.CJ
Q U Lcndet,Name 'I'O'1'AL:
LenddI comfAddry o TOTAL[
y 1 certify rM1m 1 M1uvc real this application and Wnle that the uMwe infOmtminn is BUILDING FEE
rA comet.l agree mm comply with all city and county ordinances mason,laws remnngo QTY. MECHANICAL PERMIT FEE
U Z building construction.and hereby authorize representatives of this city o enter upon the SEISMIC FEF.
.1-se-menmimoad Pro,eny for impaced (purposes PERMITISSUANCE
(We)agreem save,inm
denify and keep buml
res,the City of Criterion mounm F.LEC1'RIC FEE----.,�•�`
-
Iiondoies,judgriams,costs and expenses which may in any way mrerua mother suit City ALTER OR At)[)TO MPRH.
in »nsequence of rhe granting of this permit. PI.UMIIIN j .�EE /�„\ 1 _b
APPLICANT UNDERSTANDS AND WILL COMPLY WIDI ALL NON-POINT' AIR HANDLING UNIT(TO III,OfNI CI M) / 1 I ”' 1
SOURCE REGULATIONS. MECHAN AL/FcE
AIR HANDLING UNIT(OVIER 10,000CPM) CONSTR IO*My 2 9
Signambe of ApprOods(Imordctor Date EXHAUST I IOOD(WMUCT) IIOUSI ITIGATION PEE
IIA%AROOUS MATERIALS DISCI-OSUR17
Will the uppllam nr faore building ucenpnnl store nr M1:urJlu M1uemdOm'mu¢•rial I IHADNO IINIT(TO 100,0001111)) I
us defined by the Cupertino Municipal Code,Chapter 9.12,and the Huddi and Salthy 8
B V
Code,Seat.,,255J2(v)'f HEATING UNIT(OVER 100,000 If'I'U)
❑Yes V. VENTILATION FAN(SINGLE RESIU) PAID 1
Will the applicant or future building occupant use equipment or devices which ane ReceipuM
aero hamMous air comeminams as AeMed by the say Area Air Quality Management BOILER-COME(3HP OR IgLINX7 N'IL)
r`,o#lb,/ 'TOTAL:
DistncR BOILER-COME(OVER 100,0 0IIT'U)
EJ Yes
I have read the hacutdous materials rt meta,north,Cla ter 6.95 ofthe Cut,- AIR CONDITIONER
ymm p ISSUANCE DATE
]..I.Health,dess&Safety Code,Sections 25505,255JJ and 255]4.1 unnenland Nat i1 the NEW RESIDENTIAL MECH. SQ.I1'.
buildingJxxnnt cumtnlyn ten""moitismyresponsibiliry In notify the arcup:mt
of th uiremems whicym s met'mah,sunt tufa Cenifityaq If ,panty. 7✓
ps.
Owner or vmM1oriz ,gem 1••� p¢ TOTAL: ISSUED fly:
OFFICE /