S 0291 (2) APP LICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY '
CITY"Hi
CUI'ERTINO BUB I.DING-ELECIHICAL PERMIT'NO.
Bu11,DINGnIVISIDN. APPLICATION/PERMIT - PLUMBING-MECHANICAL C
1UIIA GI'ROJECI'IHISNI'IFICA'I'ION J
BUILDINGADDRESS: 611
3 SANITARY NO. AI'i'hICA'TION SUBhr I'ITAL DA'I'li
l0.
OWNIl 5 A Bi 1 PHONE: CONTRACIORS NAM E: - LIC NO:
i O O! NIC CON'I'ROI.X
AR HITECT/ENGINEER: LIC NO: DD $_ uaT
CON'IACC' '� PHONE: S I� .BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) RI. ELECT PLU
u1O mfuS form Or..itthe,aur nimu Basin�s and Pisairwal hirac 9o, 1m,accda ply PERM(' ELECTRIC,PERMI'I" 1'1%1% JOB
(D—DESCRIPTION
LICENSED CONTRACTOR'S DLCLARAI']ON
fthe
cale,
nd
uCZ y y I'ISSUANCE RESIDENTIAL:
1• ❑SFDWL ❑KH'CHFNREMODEL
aU(~J Licem%e Class Lot of APPI.IANCF.S—RES IDIiNT1A1. []ADDITION ❑PLUMBING RF.-PIPIT
F Z W Data Contractor
m<m - - ❑MULTI-UNIT ❑STRIICI'URAL
Fly ARC]ILI HT'S DECLARATION PANELS
Z - I understood my plans%hall ho used as public records CHIMNEY
REPA
OON
Zry—'—' UP TO Hb AMPS (]INTERIOR ❑CNIMNF,Y REPAIR
F.N.�IE Lian.sed Professional 201-1ENNIAMI'S IMPROVEMENT DSWIMMING POCHS
90� OWNER-BUILDER DECLARATION OVER LOAMPS ATI(RFMODEIJREPAIR El DEMOLITION
I hereby affirm that I am exempt front the Contractor's License[.it.fur the ,
axx06U following reason.(Section 703 L5,Business and Professions Cale:Any city or county SIGNS ELECTRICAL fHER
which requires a permit m construct.alter,improve,demolish,or repair any smae ure
prior ut its issuance,also requires the applicant far such p mai no rile a signed%mement SPECIAL CIRCUIT/MISC
$ } that be is licensd Pursuum mtbe pnrvision%nl the Comn.0"",l.im cLow(Chapter9
0 (commencing with Sm, 07(X10)ol'Division 3(ofthe Business and Professions Cade)or TENOR MEfER OR IY]LC(NST. ' OMM 12 EAI'
OL a n�' that he is exempt therefrom and the basis for the alleged exemption.Any violation of - ❑NEW BLDG/ADDITION ❑DEMOLITION
�m Section 7031.5 by any applicant hnaPermit subjects Out applicumm%civil Penalty of POWER DEVICES OTENANT ❑FOOD SERVICE
not one than five hundred dollars(8500). IMPROVEMENT
O ❑ LisOwnerofihepropeny,ormy emplmyecs with wages nx their solo compensation, SW IM M I NO POOL HLECfRIC
will do the work.and the structure in not intended Or offered for sale(Sec.71004.Business ❑O'fIIER
W �m and Professions Coi The Contractors License Law doer not apply as an owner of OUTLETS—SWITC1H S—FIXTURES
6 3 property who builds or improves themon,and who docs such work himself ar through
his it,.employee%,provided that such impmvemems are not intended attracted fm NEW RESIDENTIAL HLECIR SO FIT
rule,If.however. he, ldingn,improvement is cold within ane yamafaalldal oo,the SQ,F 4.AR VID sISQ.FI'.
owner-builder will have the burden of proving that he did not build or improve for Pur.
a of eaten _ 'JUL 14 RECI
❑ i, f Owner of the propcontracting
erty,vat exclusively mmm
with licensed cnmors TOTAL:
+mtmat the pmjact(Sce.7614,Business and lhofcsa)ans Ine)The Com
mefor's Li- -
seLorianapplytoonownerof property who builds or improves themon,and QTY. PLUMBING PERMIT FEE
who contracts for such Inemn,with a contramons)licensed protocol lathe Calamities CITY OF GurERTINO
License law. PERMIT ISSUANCE -
I am exempt under Sm. .R&P C fur this reason
ALTER—DRAIN&VENT—WATER(EA) ` yptION
Owner Dom
ODWORKER'S COMPENSATION DECLARA'ION 'BACK PLOW PR(YI'IiCf.DEVICE
I hereby l under penahy of perjury ane of the following decluratione
❑(have and willmail mainmine Ccnifica¢af Cnnsrnt maelLinsurcfor Workers Comprn- DRAINS—FLOOR,ROOF,AREA,COAD. STORIES TYPE CONSTRUCTION
satins,as provided for by Scmim o 3700 01 the Labor Code,for the performance m the
work for which this permit is issued. - FIX'I'PLUS—PHR'I RAP
❑1 have and will maintain Worker's Compensation Insurance,ns required by Section GAS—ITA.SYSTIiM-I INCA OUTLETS37(Nlafthel.No Code,battle,perfomtznce ofthe work for which this permit is issued. OCC CROUP APN
My Worker's Compensation Insurance carrier and Policy number arc: CAS—IIA.SYSTEM-OVER 4ILA)
Policy No.:
CERTEPICAT'EOFEXEMPI'EON FROMWORKERS' GREASNINDUSTRL WASTE 191HRCEProR
COMPENSATION INSURANCE? BUILDING DIVISION FEES
(Thissectionneed not becomelaudifthe NandisfornnehundrWdollan(SIOn GREASE9'RAP
or las.) 11Ur///^ry//� PIANCUECK ITE
Ice hn nthe OeHnrnenc + a/ fr "��1Dyhis Permit i.isnucd,Islall SLOWER—SANITARY—STORMEA.200FE IiNIEHGY PEG
SOL ICE T ANT:11.ober mal B(hirfik / nfemr.... .rs'CnmPen.
y' oinany roam
Z smion 1 _ice.U m WATER HEATER W/VENT/F.I ECfR
GRADING FEE
u should WATER SYSTEMOREATING
a bn a subject 0,the Workerpo
s Comosation provisions of the Labor Code,you must SOILS HE
lin@with comply withsuch provisions or this permit shot)lot deemed revoked. WAI'ERSEiRVUH
Uj
6.
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FE PAID
z I hereby aRn l that there is a construction lending agency for performance of cmpt N
U
O the work for which floc permit is iseued(Sm.3097,Civ.CJ
(<nder's Name TOTAL:
O {viI Lender's Address TOTAL:
I}. G 1 certify that 1 have mad this application and slam that the above information is BU]LI 1 F.
x
i—. On mmt.l agree m comply with all city and county ordinances and slate laws relating m Ty, MECHANIC AL PERMIT FEE
U Zbuilding conswetina,and herchy tmthorize representatives of this city m enter main the - SEESMI -E
`+ above-mentioned propcAffireinspection Purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Criterion against ELECI'kIC PER.
lialadflies,jragments,costs and apensesw>m may in any way accrue against said City AITERORADDTOMECH. PLUMBING FEF.
inconsequence of the grentinp�a is pyTvt�
APPLICANT UNDERST D'A OMPLY WITH ALI,NON-POINT AIR HANDLING ON[PTO WALL CFM) MIiCHANICA1,PER:
REGULATE,
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION
of 1Nrcam/Canm4. Die EXHAUST HOOD(W/DUCTI HOUSING MITIGATE NHE
HAZARDOUS/MATERIALS DISCLOSURE
Will the applicant or future building(occupant more or handle notorious material' I IRA LI NO UNIT('10100.0(X)BTU)
as defined by the Cupertino Municipal Code,Chapter 9.13,unit the Health and Safety
Code.Section 25532m)? HEATING UNIT(OVER 100,000 HTO) -
❑Yee No VENTILATION PAN(SINGLE RESID) PAID -
Dina aintx
WIN the applicant or future building(occupant use egnipuem m devices which• BOILER—COMP(JHP OR 100,000 BTU)emit buzardous air communicants as defined by the Buy Area Air Quality Management TOTAL:
DistrictR BOILER—COMP(OVER 100,000 RTU)
❑Yes ❑Nn
AIR CONDITIONER
(have ad Safety
h ode,Ss noted 5505,2 mnent,1255 .I and rsta and the Cali- ISSUANCE DATE�
fnmia Health&Safety Code,e.t 25505,issmy and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.I'I'. IO`y////I
building ricesnotcurrency have.tenant,Anto ismyofit crucoceofythetrel,
of the requirements which mud he tact poor to ofe Ceni(am of(kcupancy.
Owner.maturated agent Dae TOTAL: ISSUED BY:
OFFICE