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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUI'ERTINO BUILDING. ELECCRICAI,
RU)I.DING DIVISION APPLICKI'ION /PERMIT PINGROJECI1DENI ICAL
. I51111.DING I'NOJBC'1' IDI +.NI'IIrICAT10N
Pea ITNO,
3117
BUILDING ADDRESS: / j
S de w,4 G I%r
SANITARY NO.
APPLICATION SUBMI MAL DATE
%1 — %)' 76
O 'S AAME. -9 1 P110NC,9�I'
V
CUNT CCOR'S NA kV // LIC N(
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❑
- CONTROL
LIC N
NCHITEC'FIENANIZE O;
ADDRESS Sr
w =Y /�� (
COrvincT: PHONE;
BUILDING PERMIT INFO
❑ COnsullanl Flies Paid by Applicant(initial)
BLDG ELF;CT . I'IOMHH MECH
S3 ✓)�Ig
LICENSED CON' TRACTOR'S DIICLARA'I']ON
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
QTY.
''" ' laLECT'RICpE12MITr -
,aFPI °,
JOB DESCRIPTION
PERMIT ISSUANCE
wan Sectiomu0ol of Divi.dan 3 arm, Bu iae., and Profession, Cale. and my liven, is
in Full force 'end effect.
RESIDENTIAL:
❑SFDWI, ❑ KITCHEN REMODEL
-
AI'PLIANCIiS- RIiSIUliN3'IAI.
Liamee Class Lic.a
Dole Corprolar
❑ADDITION a}YL'�MRING RGI'll'li
❑MULTI -UNIT ❑STRULTURAL
MODWICATION
❑INTERIOR CHIMNEY RCPAIR
IMPROVEMENT SWIMMING POOLS
ARCHITECT*S DECLARATION
nmdammnsl Iny plans shill be useA u, public rccnaK
PANELS
Ill'T02nu AMPS
Licensed Profiromeal
2(11- 1000AMPS
OWNER BUILDER DECLARATION
I hereby alfinn that 1 am exempt Irmo the Contractor'% License Law for the
fallowing reason. (Suction 7031.5, Rusin, and Pralesnions CnJ, Any city or county
❑ RATH REMODELIREPAIR ❑DEMOLITION
❑ OTHER
OVER 10X0AMPS
SIGNS MAIM RICAL
which recruit a permit to construct. alter, improve, denalish, or repair any Ummere
SPECIAL Cl RCUD' /M ISC.
prior to its issuance, also requires the applicant for such permit a file a stgaeJ%tammen
I hat he is licensed 'm oamt In Brc pmvi%ianc of the Cammders Limn, Law (Chapter 9
(cnmmcneing with Section 900pol Dlvlota, 3 afthe Business and Profession, Cndc)or
_
I' EM I'. MIS I lilt OR DOLE INS I '.
COMMERCIAL:
,bat he is exempt ,henchmen and the Fries for the allege) exemption. Any violmme of
❑ NEW BLDG/ADDI'I'ION ❑ DEMOLITION
Section 703 0 by any applicant for a perout subjects the upplicam nr a civil penalty of
mutation than rive hundred dollars ($500,
r)1.ayownernfliepropeny,or my employees with wugec as their sole eonquncn don,
POWER DEVICES
❑TENANT' ❑FOOD S17RVICI:
IMPROVEMENT
SWIMMING POOhIJ.IiC I'IHO
will do the work. and the stmcmm is not intended or offered for me (Sec ](44, Business
and Professions Cale: The Contractor's License law arcs not apply al as owner of
OUTLETS - SWITCI IM - FIXTURES
pmparty who bails, or Improve mcrenn, and who )acs such work hiensdf or through
his awn employees, provided that such improvemenrc are not intended or offered for
sale If, however, the building or improvement is sold within one year of completion, the
NIIW RES I DENTNh ELEM R SO FI'.
'Q, PI'. FLOOR AREA
ESQ. PI'.
caner- budder will have the burden of proving that he did not build or improve far put.
po,eul'sule.)'
1, as owner of the progeny, am exclusively contracting with licensed read... has to
' OFAL:
asuroarma,he prejea, Xay. 30W4 Basin,.. J Isminwicato Cale) The —n Li;
- t
r, n. I 1 t. pplyt fp p ny h m n
nI
QTY PLUMBING PERMIT .
FEE '
sun r ie a as ronmdpureu �thc(' rc
p 1
..• '..
'
PERMIT ISSUANCE
(u
r9ruumt�
Lic I >
,Law
❑ 1 cacmpt mNcrSC It &PCfonh re
Owner 11
AL TER- UItA1N &VENT- WATP.R (EA)
_ VALUA'110N
�IC
WORKERS CONOANIISAT A O
1 hereby affnn ruder lwe, dperjnry�he lnllowing declarefinns.
]Ihuvenndwill nntintainn Ccrlilic.edCnnscmmndf- Insomnia WnrAer'xCompum
,efi9n, m pmvideJ for by Section ?]I 1 �' the LuMsr @Me, for the perfimnunce of '
RACK FLOW PROTE(TE DEVICE
DRAINS - FLOOR, NOOP,AREA, COND.
STORIES
TYPECONSTRECHON
work far which this permit is issued,
I'IXq'UkIS - PER'IAAP
�.Lkutc and will mainuin Wmker's 'alien I and M1y Section
GAS - IIA.SVS'CIiM - I INC. 4OUTLETS
3700ol tlw Lanor CuJC, lin'Ihr : PCrfomt mto rwhidn tai, purmll rvisweol,
OCC. GRUDI'
nPN
My Wurkv' 'top aatio sea ee and Policynunly yC
Carrier. t miry No
GAS - EA. SYSTEM OVER 4 G:A)
C17 R11 IFI MOVES: '1'ION FROM KERS'
COMPHNSAI ION INSURANCE
('1 Lis section need nnl M+rnmple¢A ifthelrcmnil is for nnc hundred Anllars ($ 100)
or less)
GItF.ASI %INW59RI. WASTIi INTERCEPTOR
NUILDING DIVISION ('131 :5
GREASG'FRAI'
1'LANCIIIiCK IIiP.
I cenilydat in the perlimmmnce afire work forwhich this permit 1, issued l shall
nnI and" hey person in say numn9r ut us m baconm mhjeet to the Workeri Crandon-
SEWER- SANITARY -STORM EA. 200 FC.
WATER HEATER W /VENT/F.LECTR
,.,ran Laws of California. Data
Applm at
GRADING FEE
NOTICE '10 APPLICANT ;II; nfermikingIn, Ceti licme of Exemption, you %hou Id
heaven mhjeet m the WorkeBS Campemal into pnwi%ion, of Ile I,ahor Code, you nmH
Fonhwi,h comply with such provisions an this permit shall he Accmed revoked.
WATER S YS 'I EM/IRCATI NO
SOILS FI!I:
WATER SERVICE
l
NEW RC:SIDENI'I Al. PLM9. SQ. FI'
CONS' I' RUCTION LENDING AGENCY
1'AlD
Data Recd',#
Ihereby affirandinmere isacon,tmginn lending agency Far he tie, jancm,u of
_
the work for which this pendit is issued (Sec. 3097, Cie. C.)
Lender's Name
TOTAL:
Landers Adams,
T
L
BUILDING FEE
1 amity that I have read this applicalion and state that the above ianneratimn I%
sect. l agree to connply with all city and county infamous and sure law, relating stn
h ] did, caohdnrian, sad herebyaummim rearaWrutivp of tolesayto antes neonthe
QTY. MECIIANICAI. PERMIT
rEE-1.
SEISMIC 11E
I'RRMI'1'ISSlANCE
ELECTRIC ITH
nhnvo-munlinnW propcdy For in%pemit pugw e"
(WC)ugme m save, indemnify and keep Luanlc,sthe Cityof Cupcnlnoagainst
ALTER OR ADD TO MECH.
PLUMBING FEE
liabilidw,judgmems. costs and expenses which may in anyxayicemea ,unNimm City
in conse:pmnm of the gain tIIngof this Tmit.
AIRHANDI ANGIINI'I'(1'0110.00CNM)
MECHANICAI,FEF
APPLIC ANT U ST DS WII-1. COMPLY WI', H ALL NON- POINT
SO RCP L'I
AIR HANDLING UNIT (OVER 1I,000CFM)
CONSTRUCTION TAX
�Clr Sff
Signatu Ap mTVC tlor Data
DAZARDOUS MAI ERIALS DISCLOSURE
EXHAUST I100D I WIDUC'1]
HOUSING MI 'I IGA' I' ION FEE
Will the applicant or future building occupant some or handle hmallouc material
HEATING UNIT (TO 100t0g) If TO)
ns delinW by the Cupurdnn Munialp :J Code, Cbupmr 9.12, walnut Health and Sufmy
Code, 9mtlon 25532(,)9
HHACING UNIT' ((OVER 1011,(lllfl Itl'U)
❑Yes Fl No
PAID
VENN ILAGON FAN (SINGLE R MP)
Date Receipt a
BOILER - COMP (31IP OR Idp,IX)O B'IL)
Will the applicant or fume, building .unpa d ash equipment or deviwv which
anit hamrdous air cantaminana as derived by the Ray Area Air Quality Mnnngento
Dls,dm?
[:] Ycs Q No
O
O
BOILER - COMP(OVER IW,W)BTU)
,
AI k CON DI ONIiN
I have read the hndendr Us materials reyuircmcntc under Chapter 6,95 of the Cali-
ISSUANCE DATE
NEW RESIDENTIAL. MECI. SQ. FT
fomia Health & Safay Cole. Suctions 25505, 25533 and 2553). 1 understand that if the
building arcs nut currently have a tenant that it is my responsibility to notify 0m uccupard
�TQ ,
of the requirement, which must be met prior m is,n awr ofa Ccnilicme of Umupaa,,.
r /
ISSUED IYY'.
TOTAL.:
Owner or amhnrimd agent Date
OFFICE