S 0019 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
+R - BUILDING ELECTRICAT PERMITNO.
CITY DI COPVISION C�_1 q�
BUILDING DIVISION APPLICATION/PERMIT PINGRINO-7,H)EN I1F1C s1i a" ( U
' ;, BUILDING PRO,(ECT+IUftNTIFICAT'IUN:F(}"hpe`+;• �t
BUILDING ADDRESS'. - - - - - SANITARY NO. APPLICATION SUHMI'I'I'AL DATE
--
OWNER'S A L: Pf10NF:: CONTRACTOR'S NAME: LIC NO',
V% \ -NIC CONTROL#
YL
.JWMiCHITECT/ENGINEER: LIC NKf ADDRESS: ❑
CONTACT: PHONE: ` BUILDING PERMITINFO .
❑ Consultant Fees Paid by Applicant(Initial) In DO i ELECT PLUMB MECCH
LICENSED CONTRACTORS DECLARATION QTY, f t ELF-CITRIC PERMiT. FEE
to
1 hereby affirm to I I licensed a p r chapter 9(emmmen g r x. . 'r�i JOB DESCRIPTION
aaz w'ds ton 7000)ofDor
n3ofmean ktassure!Pr became,Cede ,td an,license is
1+100ISSU
i IT ANCE
F in full force and effect PERMWL ❑KITCHEN REMODEL.
Q,UU License Class If,.# APPLIANCES-RESIDENTIAL lqyo ❑ADDITION ❑pLUMBiNG REPIPE
rF�W Date-Contrmtnr ❑MULTI-UNIT ❑STRUCTURAL
ARCHITECT'S DECLARATION
Z Omers
z I undtand my plans shall M1e used as public redorJs PANELS MODIFICATION
Ozfgo UPT0200AMPS El INTERIOR ❑CHIMNEY REPAIR
W Licensed Professional 201-IOMAMPS - - IMPROVEMENT SWIMMING POOLS
W OWNER-BUILDER DECLARATION
I hereby afn that I exempt from the Cnm
memr'a License Law Tee iha OVER 000AMPS El BATH REMODEIJREPAIR
ftmem DEMOLITION
O U following lawn.(Seat itn 7031.5,Business and Profewicam,Cede:Any city or county SIGNS ELECTRICAL - ❑OTI4ER
W 3 W y which requires a permit to construct,alter,improve,demolish,or repair any sweruro _ -
0-' priterm its issuance,also requires the applianlforsuchpumite,fileasignedstatotnent SPECIAL CIRCUIT/MISC.
licensedpnrsuanunthepmvisimnsoftheCmmroctnraLimvseLaw(Chapter9 _
F900 (eommdncing with Secton 7W0)of Uivision3 of the Business and profensinns Crde)or 'TEMP.MF.TF.ROR POLE INST. OMM R IAL•
11pt c that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W N Section 7031.5 hy'uny applicant roe n permit subjects the applaral to recall pouchy of POWER DEVICES ❑TENANT ❑FOOD SERVICE
Ftonc than five trundled dollam($500). _ IMPROVEMENT
-+� nor...�I,as owner of the pmtperty,or my employees with wages as declared,ompensation, SWIMMING POOL ELECTRIC -
s(dll do the wrrk,and the structure is not immrdedormffered for sale(Sec.70,14,Business ❑OTHER .
aand Pode"nues Code:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES 3e
property who hands•or improves thereon,and who docs such walk himself rr through
his own employees,Provided Wm such improvements me not intended or offered for NEW RESIDENTIAL ELECTR - SQ UIL
salc.If,how ever,the building car lmpdvncinr is sold within one your of completion,the - SQ.FE FLOOR AREA S/SQ.FT.
owner-bal Trier coil)have the burden or proving that he did not build or irapture(tr per- _
pose rfsale.). /A
E]1,as owner of the property,am exclusively contacting with licensed cenbunmee to-
constructth project(5 7044 R . dProfessions
CJ )TF Continent's L ( -( py+,
cenee Law due,int.ppl,1 fp pet, he hands or haprovic,headmi, d �QTY.",'i�(t ) jPLUMBNG PERMIT?1 xr: t• II sr j3 PEE,
who contract,ftrvud project vvtha cmnraetem,)licensed Forstmann 1.he Conbactors !
License law. PERMIT ISSUANCE I -
❑1 m under Se. ,B&P C for this reason
ALTER-DRAIN&VENT-WATERO ) VALUATION
owner ex � Doe ,
RKE SCO NSATIO ECLARAI'[ON BACK PLOW PROTECT.DEVICE D Q
afrirm soda curb
rf a eofthafmmefo Worker
2 O
5 P Y P(iury nn g -
�Qlhavc and wiEmaintain etion3amof he Labor
Code,
Wodersewofthe DRAINS-FLOOR.ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
scorn, r which this
fpemi Sermon 3700 of the Labor Code,foe the performance of the
work for which this permit is issued. YI%TURES-PF.R TRAP
❑1 have and will random Worker's Compensation Insaranev,as editorial by Section _
37M of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC GROUP APN
- My Workers Compensation Insuranw,artier and Policy numda are:
Carrion Policy No GAS-EA.SYSTEM OVER 4(EA) ,
• CERTIFICATE OF EXEMPTION FROM WORKERSGREASF/[NDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE R IL LNG DIVISION FEES
(This aectide need not be,ampleted ifthepermir is forme,trained unit...(Slub GRHASETRAP
orlew.) _ PLANCI RICK FEE
I ednify that in the perfmmnnecrfiheworkfur which dos pennitlsissucd,lshall SEWER-SANITARY-STORM EA.200 FT.
not employ an rs in an moaner so as to become suh'ecu drum Workers'Com en- ENERGY F
nn ) p
0 zi action Laws of California.Dote WATER HEATER W/VENT/HLECTR GRADIN FP.E t �^
Q Applicant t i vvi L
N NOTICE TO APPLICANT:If,after making this Contribute of Examen a,you should WATER SYSTEMRREATING
[" become subject to the Worker's Compensation previsions of the Labor Code,you rams SOILS FEE
LT7 G forthwith complyprevisions with such pvisions or this perent shale be deemed mvoked. WATER SERVICE
Q
z CONSTRUCTION LENDING AGENCY NEW BESIDE N'1'IAh PLM B, SQ.FIL PAID Dule ecei ted
I hereby affirm riot there is a utingmction lending agency for the perfonnana of p
U the work for which this smal is issued(Sec 3097,Co.C)
Lender Name - TOTAL:
V i,end 'Add - T TAI I
(3I bt 1 HUILDINO E D
a 1 t[y tl til dd:'Ppi t d tt th'uh '
.a rA cae I g t ply e with any d ry rd' d t Itotalingt QTY
mt .i t 1iMECHAN1CAl PERMIT •
t `' FEEL ''
V bold g :I urtion dh M1y th p t F es rf th;ctytoemm�p rube ,n l- /' '+ + I. SETS FEE
above mentioned property for inspection pt rposcs PERMIT ISSUAN(U
(We)agree m save,indemnify and keep huntress the City of Calderon against - LLEC'fRl -FEE
andelities,ridgmemx,costs and expenses which may is any way accrue agaimi,sid City ALTER OR ADD TO MECH.
asequence of the granting of this permit. PLUM9IN PEB
(APPLICANT UNDERSTANDS AND WILL COMPLY WI ED ALL NON-POINT' AIR HANDLING UN I GTO 10,000 CENT)
SOURCE REGULAIONS. �. MECHANIC PGE
L
T
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCT( N,TAX
Signmere of Appeicanl/Conrmea r Date EXHAUST HOOD OODUCI) HOUSING MITIGATION PER
HAZARDOUS MAIERIALS DISCLOSURE
Will the appl'manmmicre bonding',cupamoine in handle haiadrusmmerial HEATING UNIT(TO Enthral BI U) -
is defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Salary -
Code,Section 25532(x17 1[HATING UNIT(OVER 100.000 BTU)
yes El No
'- VENTILATION PAN(SINGLE RESID)' PAID Dale Receipt#
Will the applicant or future building occupant use equipment or devices which 1 -
m heeerdras air contaminants as defined by the Bay Area Air Quality Managunem BOILP.R-COMP CUP OR 100,001 BTU)' YfA r
❑Yes E_]No BOILER-COMP(OVER 101,000 BTU) -
I have read de hawdous materials raryirememe under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forme Braga&Safety Code,Sectioas25,105,25533 and 25534.1 understand that Plan NEW RESIDENI'[AT,MF.CH.+ SQ.FT. z
building does not amerely Lave a tenant,that it Is my mepnneihillty to notify the occupant /r
of the requirements which most he met prior o issuance of a C,nlricute of Occupancy.
Owneroeaud ori cd1.Xdm Data TOTAL: ISSUEDBY:
OFFICE - '