B 0358 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO RUIhDINf.-ELHCI'NICAL k PERMIT NO 0 3 5 8
BUILDING DIVISION APPLICATION/PERMIT DING PROD cr IDE FI IFIC. .J�
BUILDING 1`ROdBCT IDE:N'1'INICAI'IUN
SANITARY NO. AITIACA1'ION SUBMI'I'IAI,ONE
BUILDING ADDRESSn/:
l
OWNER'S NAME: PHONE: RACTOR:S NAME: LIC NO: N/C COND ROLg
CRs - "o- ° 3 Z
L
RGHI'1'li /ENCINEh LIC NO: ADDRESS'.
n —r
CO fACI': PHONE: BUII,UING PERMIT INFO
e/7��rn,^'`. `--rLK � —� ❑ Consullnnl Fees Paid by Applicant(Initial) HLDG_. FLECI FLUME
CH
LICENSED CONT'RACTOR'S pF.CLARATION QTY ELECTRIC PERMIT FEE IrJ•I JOB DESCRIPTION
O - w+ I hereby uRrm that 1 am licensed under provisions of Chapter 9(commencing
7 'tb Scetion l(NXp of Uivivinn3.fthcBminusx end Pm@,,done Cole.mA my license is RESIDENTIAL;
p,1�Z PERMIT'ISSUANCE ❑SP WI, ❑K I'ICHEN REMODEL
FC n rapt timet and idem.
QUO License Class 1-11 Is APPLIANCES-RESIDENTIAL DDITION ❑I'LUMHING RE PIPE
.Qw Dale Cn"Inclor ❑MULTLUNIT El STRUCTURAL
ARCHITECT'S DECIARATION PANELS MODIFICATION
OZcA' I undersmmd my Plunssimi b:usedas public records UPTO200AMPS
❑IMPROVE ❑CHIMNEY RI?PAIR
F:+�I-II� Licensed Pmfc,niomd 2UbI1NX)AMP5 IMPItUVI?MINT []SWIMMING POOL$
�YF,� OWNER-BUILDER DECLARAI ION OVER IIXp Ahf l'S ❑Bad It REMODELIREPAIR ❑DEMOLITION
C C Q 1 hereby afna that 1 am exempt room the Contractor's License Law for Ne HER
X O W U milowing reason.(Section 7031.5,Busiix,a,m l Professions Code:An,rEY orcoumy SIGNS ELECTRICAL
W 3 LL 1-d which reclaims a permit to contact,shut,Improve.demolish,or repair any structure
F�OJ prior, I L r4 'Ib 'Pp I''nll s IIacrinitt file a signed statement SPECIAL CIRCUIT/MESC.
that he is liermellpursuant tthe Pro kion,oftiCmunicuo,License L (Chapter)
C�Qa (mmmencingwth Sml.n'/(XXI Division 3 of the Busncs.and P f: Code)nr TEMP.METER OR MILD INST. COMMERCIAL:
W a o°a that he is cwmpl therefrom and the basis for the allege)exemFour.Any violation of [I NEW BLDG/ADDITION [I DEMOLITION
n
I4 Seetion7031.5 by any applicant for a permit subjects the applican °"civil Penalty or POWER DEVICES ❑TENANT ❑FOOD SERVICE
r� not norm than live hmdrul dollars(&5110). IMPROVEMENT
1,as owner of me Property,or my employees with wages as their sole c°mleroution- SW I M M I NO POOL.Pi.Ec rRIG
will do the work,and the,mcc u e is not intended mattered for sale(Sec.7(W.Business [I OTHI?R
F OUTI.1:1'S-SWI'TCHIS-FIXTURES
3
It and Property
who b Gs or iThemp Comment's L nd w law Jens not apply s an.lama of
through
his own who builds or improves Neuron,and who)nes such work deed or oreIred f
his: ennPlnyms,provided That uteh Itnpmvemcnb'hm not intended or nRco:d for NEW Nlil'IDEN'1'IAL EhECI'R SQ FT.
sale.if.Nu rvem the huadingorimpmvemmat i—cild Mdounne yra,"I"a"Plctiou'doe �j SO Fr.PLO(1N AREA $TSV PI'.
nerbuildcr will have the burden of proving that he did not build or improve for put- 6 / C—
r of the property,am exclusively conuaming with IicenttJ ennlracwrs to J
< nxtma Ihesprojecl ISeu.'lIW4,pusinces unJ Prn[cssimnx Code:?The Commclors LL
sec Lnw Jm,nm apply man.wner of pmlMnY woo builAx or nnpmvcs mcrmn.and QTY. PLUM RING PERMIT PEC
who mntmc,for such projects with a cnmmaortsj IicenseJ pumuanl In the Con°ucmr's �1
License law. PERMIT ISSUANCE L-
❑lamexc tmnaer sec. .pffircr.r mise rcanr
AI:1'liR-DRAIN&VIiNT-WAIT:R(FA) VAIDAT )N
ter pact /Z 3. O 00
WOlt Kli COF iNSA'f1ON DIiCLARATION I1ACK I'IAW I'RIYI'IiCI'.DEVICIi
1 hereby aRrm under penally or Perjury one of the Edl.wing Jedemtinm:
r]IhavwnJ will main,ina Cenificmud Consenu.xlGinsurc for Workers Compen- pRAINS-FLOOR.R000.AREA.COND. — TORIES I'YI'Ii CONSTRUCI'[On
w.rk
a al M1 this
hMs by5 i l]W ffN LaM Cd.forty pert rm of me //S` I
l permit isissued FI%TURES PER TRAP
E]1 have rand dinountain W k ':C nap f....In,noult,a,out,dred by Sort on UCC. UI' APN
310(1 of(he 1 M Cw1e.for M1 pet rt ncc fth kf rwh FII :P tri is issued GAS-I:A SYS]I:M lINC40U'lI,I5L5 I�I 2 019
My Wlakds Comparted..Insurance comer and Policy norther arc: GAS' HA.SYSTCM-OVER4UA)
Carrier. Policy PI
CERTIFICATE OF EXEMPTION MOM WORKERS' GREASEJINDUSTRL WASTE INTIiRCEPTOR
COMPENSAHON INSURANCE bUIIAING U 1310th P[ipS
(T his section need ern ace nplmcd ifthe pem,is hnonc hundred dollar,($1 BE) GRUASETRAP PLANCI rC '7p.z
or less.) ER - -
Ioyanyprsnlheperfovnenccofhewask
cturewMjectch totheWs man isiss'Compe11 SEWIiR-SANITARY-STORM IiA.2(p FT. ENPR h'
not employ any person in any manner so as m become subject to the N'nrkcrs'Compen-
Z 'tion Lows of Culdo nia.Dole WA'T'ER HEATER WN17WXLECE R GRAD. 1:F.
zQ APpllaunt 1
.Na NOTICI?TO APPLICANT:If,taller making This Cenilicste of Exanptio".You should WAT 11 it SYSTEM/TREA'T'ING SOIL. .1;
become suhject to the Workers Compensation pmvisinms of the Lahr Gde,you must
forthwith comply with such pmvisiom or this Permit dull be deemed revoked. WATER SERVICE
] PAI
A' CONST RUC HON LENDING AG17NCY NI:WRESIDENTIAI,PLMN SQ.FT.
our" Reairt a
UQlherchyarfina mmmereis.construction lmtding agency lar dic Performance of
Ina work fm which his permit is issued(Sec.3(19'1,Civ.C.) TA.: Z VC
Qf•" Lenders Name TOTAL:
Lem(c/s Address BUILDI G +E
1 certify that I have mad this application and.elate that the ahrne Information is
correct.I agree"I lonnlly wim all city and many ordinances and state laws relmlng t. QTY. MECHANICAL PERMIT FEE SE:IS I, 2
VZ building ummmnion.and hercM1y aumoriae nprcsemative.wfthis city to emerupmthe t
sbovermmtioned .,nY for i"speelion Purposes. PERMIT ISSUANCE I I. I .FEE j 3
(Wt,)agree to insist,indemnify and keep hmmless me City of Calandra against
liabilities.judgments,costs and expenses which may in any way accmmgaiml said City AITER OR ADD'I'0 MECH. PL ING F.E 3
i"Iamw,nc.vr of the granting of thlx permit.
AI'I'LICAN'T UNIIP tS'1' NDS AND WILL COMPLY WIHI 1N-POINT' Apt HANDLINGUNI'I'TTOI(),IXNICI'M) M '11 11 IH? e
SOURCE RE r' f
J6
Alk HANDLING UNIT(OVER 10.(XM)CFM) Co. -1' TIO TAX
igna roof AP canVConmecan Date EXHAUST HOOD(W/DUCry HOUS GMI IG TION FEB
I IAZARDOUS MAE 111"ALS DISCLOSURE
Will lhen,licant or fulure building nccupumclore nr handle hazard..,anterial HIS'TING UNIT LTO 11101000 111
m,defined by the Cupertino Municipal Cdr.Chapter 9.12,and the Health and Safety IIF.ATING UNIT(OVER 100.001 BTU)
Cafe,Section 25532(a)'f PA�
-1 Yes ❑No ' VENTILATION VAN(SINGLE BESIDE Dae Remipl6
Will the upplmi m or future building sceupvnl use c9uiptnem or devices which BE did; -COMP FEIDI OR 100,000 EI'IU)
mit harardous air con,minanu as JeOned by the Bay Area Air Quality Managsancnl .R
Di'morl? BOILER-COMP(OVER 10RIp(113'1 In
Yes El No
AIR CONDITIONER ISSLANCE DATA
I have rend the Encomiums ode,S ,tion,5.5 rc.25533 na andel Chapter 6m5 of the m Coh.if,he l 2-
a
-f
fomla Halm ffi Sultry Csdc.$eaten 2.5505.25533 and asibil 1 understand mat if the NEW RESIDIiNTIAI.MECH. SQ.let (/ /
a 1J2a ties not meetly have atcnam.that it is my rcsrymsibilly mnolif0ce occupant ey. e.- / l
of the s wh[h must be met prior IU izsuunce of -<n,,eaa of Oce ancy.
Owner vumnrireJ xgcm Jmc T(1'TAIs ISSUED BY: �®
OFFICE