S 1382 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OP CUPRRTINO BUILDING-ELECTRICAL - PERp11T NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL vc
auu.DlNc raoJh:CT mENTIFIcnnoN
1382
BUILDING ADDREi55n SAND'ARY NO. APPLICATION SUBMI'TT'AL DATE
O ` e ��
OyGJER Ne Cts 0 6 44 6—�3 8�, COVI'RACIY)R:S NAME LIC NO:
l/i" NIC CONI'ROLp
ARCI IITEC'I'/ENG NEE.: LI NO'. ADDRESS: ❑
CON ACL CION BUILDING PERMI'I'INFO
l ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENS,DCONTRd IURS under
Of CON QTY. ELECTRIC PERMIT FLEE
1 hereby alarm that 1 am licensed under pmvisiI..of Chapter 9(mmm�enaing JOB DESCRIPTION
ypj�Z with Section]d effect.
Divisinnlof the ausinese and Professions Code.and my license is RESIDENTIAL
H,WO in full force and,Beet PERMIT ISSUANCIi
aU-U License Claes Lic.p GSPDWI. El KITCHEN REMODEL
I1..Zw Dae Contractor APPLIANCES RE
InQL [I ADDITION D PLUMBING RF.PIPE
ARCHITECTS DECLARATION
Z Fp tes ZZ l undersand my idmo,hall he used as public records PANELS ❑MULTI-UNIT GSTRUCNRAI.
C)Z 4 D UP TO 2ql AMPS MODIFICATION
1-GeLZs.Fsm Loccnscd Rofesvonal El INTERIOR C3 CHIMNEY REPAIR
99 Fo,',4 OWNER-BUILDER DECLARATION 201-100AMPS IMPROVEMENT E]SWIMMING POOLS
y O zw Q 1 her,hy affml that 1 am enempt from the Cnmraclnr's License Law for the OVER 1000AMPS ❑RATH REMODEUREPAIR [I DEMOLITION
S.U following reason.(Section]011.5,Business and Professions Coca Any city or county D OTHER
{s7'T F SIGNS ELECTRICAL.
F.=0,11e wh'nh assim cs a permit m conswcl,alter,Improve,demolish.or repair any auveMrcles
yJ prionons issuance,also regmres theapplmrm forsuch pe.inti fileasigned statement SPECIAL CIRCUIT/MEC [
} that he is licensed pursuant o the Provisions of the Contmenrs License Law(Chapter 9
00 (0OOmencing with Section 91NI0)of Division 3 of the Business and Pull cscions Cade)nr TEMP.METIER OR POLE INST. COMMERCIAL-
that he is exempt thertfmm and the basis for the a11egid cumption.Any violation of ❑DEMOLITION
-1+y Senion]Nl.5 by any applicant for a permit subjects the applicant m El NEW Bf.IXi/ADDITION a civil penalty of POWER DEVICES
It not mare than live hundred dollars EiNgn. 11TIENANI ❑FOOD SERVICE
SQp D 1,as owner of the property.or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
F will do the work,and tho,mamre is not intended oroffured for sale(Sea 9(H4,Ilnsiness DOTHER
3 and Professions Cade.The Contractor's License Law does not apply in an owner sit OUTLITTS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such wak himself or through
his Own enmloyeea,provided that such Improvements aro not intended or oflbred ha NEW RESIDENTIAL.ELECTR SQ FP.
aide.If.however the building torr impnsvement is.cold within no ye a ml ommplei.alhc Q SQ.III FLOOR AREA $ISQ.FT.
w'at,gilder will ham to harden of proving that he did not build or improve far per-
p a sown,
of We propcnY•am exclusively commning with IittnscJ c.mmn.rs to 'n
ton the project(Su.)844,Business and Professions Cnde:)The Contmcmrs..i-
cense Law docs not apply to on owner of prolwrty who builds or Improves thereon,and QTY PLUMBING PERMIT FEE
who contracts for such projecu with a commnogs)licensed pursuant to the Contractors
License Law.
❑ 1-111 allaINunder See. ,B&P C Earthia mason PERM IT ISSUANCE?
Open ("'(-��'- AUIER- RAIN&VENT-WA VALUATION
WORKERS 'OI PRNSA'1'ION DECLARA'fID)amN�IT- BACK P ROTIECT.DEVICE
1 terchy alfhm under penehy of pe jury one.(the following Jcclmauons:
I have and will maintain a Certificate ofConwedin self-insure for Worker's Compete DRAIN. -F, )R,ROOF,AREA,COND.
All
sition,as famished for by Seclion 3]00 of the Labor Code,bar the pcparepa ce of the S'I'G IES 'TYPE CONSTNUCfION
work for which this permit is issued. FIXTURES-PER AP
❑1 have and will nainain Worker',Compensation Insurance,as required by Section
3]glnfthe WMn Cale,fonheperformance of the sand fur which this pcnnit is issued. GAS-EA.SYSTE I IITLUTS OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy mortar are:
Carrico Pul icy Nn.: GAS-RA.SYSTEM-OVE U
CERTIFICA'IF.OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR
(This section ncmlnotbecomplcted iDhcpermit is for tine hundred dollars($100) BUILD ) ISIONFP,RS
.floss.) GREASETRAP
PLANCHECK FEE
I certify that in the any Performance ofthe
us I work for which this permit is issued,l shall
molenlpiny any peaonin any manner cous In become suhjecnn the Wmrkers'Cnm SEWER EA.2110 FI'.
O ,� cation laws of Cali[.mia Dam poo. ENERGY FEE?
7 O Applicant WATER HEATER W/VEM'AeLECTR GRADINGME
y NOTICE TO APPLICANT:IL after making this Cenilicom.1 Eaemptina.you.should WATER SYS]'EMlfREATING
a ; become subject to the Workers Compensation provisions of the LaMn Code,you must SOILS FEE
sti forthwith comply with such provisions or this permit shell be deemed minded.0. q WAl'IER SERVICE
Z CONS'I'RUCf10N LENDING AGENCY NEW BESIDE IAL PLMB. SQ.ET PAID
L) I hereby xlfimrthat there is amnsmoubou lending-g acy for the part..mance.l Data Receipttl
LZ I~ the work for which this pemlil is issimd(Sec.JOYS,Civ.CJ
Lenders Name
0II Lender's Address ` D TOTAL:
y 1 cenify thm 1 have real this application and.a thm the above imfemlminm is BUILDING PT:F.
VtQ correct.l agree to comply will,all city and county otdinanre,and state laws excludingm QTY. MECHANICAL PERMIT FEE
building wnstnmtion,and herby nuthariu mprwentmives.f Ibis city renter upon the SEISMIC FETE �a
abovcmemtioned property for inspection purposes.
(We)agree to,ave,indemnify and keep harmk,s the City of Cu ninny PERMITISSUANCE
Iiabidines,J•ments,costs and ex Pe against ELECTRICI[E
6 thisPsmit. lnay in any way aecmengeinst euiJ City ALTER OR ADD TO MECH.
in coAPPLnsequence cc N the gaming of this permit PLUMBING PEE
SOURCE
REUNDE.STANUS AND WILL COMPLY WI"fH AL1.NON-POINT AIR HANDLING ONE"P(TO 10,00 CFM)
SOURCE.RIEGULAq'IONS. MECHANICALME Q `
AIR HANDLING UNIT(OVER I0,000 CFM) CONSTRUCTION TAX
Signature of ApplincoUCertmamr Data EXHAUST HOLD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FETE
Will the applicant or future holding occupant store or handle htnatdmus material HEATING UNIT(TO III(ITU)
as defined by the Cupenar,Municipal Code,Chapter 912,and the Hatch and SaRty
Cale,Section 8512(x)^ HEATING UNIT(OVER 100,000 BTU)
Vol FjN.
VENTILATION PAN(SINGLE RFSID) PAID
Aft Will the applicant or future building pan equipment [).to Receipt x
III PP gby th fusee Quality
Management
BOI I.Eill-COM P(3 H l'OR 100,000 BTU)
emit District' ons air contaminants as trained by the Buy Areca Air Quality Munagemenl O
Distrin^
❑Yee [D No HOILER-COMP(OVER 10B00BTU)
I have mad the hmallous materials uirements candor Cha AIR CONDITIONER ISSUANCE DATE
ay pmrfi9nd that Cali
fomiu Heath ne Safety Calq Sermons 25505,25513 and 25534.1 understand that if the NEW RESIDENTIAL MECI I. SQ.ET. ( -7 ,-
builJing fires not currently have a tenant,thin it is my resrymsihility m nmify the tecupam l
of the taluiamenb which mast be mel prior to issuance of a Conflicts,of 0ecurynry. T
Owner as constructed agent Data \ ISSUED BY: �+ i
OFFICE