S 2188 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUl'ERTINO
BUILDING-ELECTRICAL PEIy11T NO.
ItUIL HNG UIVISIDN APPLICATION/1'ERMIT 1'LU.MItING-MIYCHANICAI. `V
WILDING PROJF.CTIOEN'FIFICATION 2188
BUILUINGADDRESS: /'. aNIIARY NO. APPLICATION SUBMITTAL DATE,OWNF4??2— ���V ��II��. CO RACTOft:S NAME: hICNO: ��bye, e _ -1 y CON ROARCHITECTiENGINF:ER: LIC NO: ADDRESS: OXY
CONTACT: PHONE: BUILDING PERMIT INFO
(�'j ❑ Consultant Fees Paid by Applicant(Inllial) BLDG ELECT' PLUMB MIiCFI
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby affirm that i am licensed ander provisions of Chapter 9(commencing
C0Z with Satlam](In(Bof Division 3oDhe business and Nofcssinns Cale,and my license is RESIDENTIAL
n10 PERMIT ISSUANCE
F1_ in fu[iforcc and effe s3o 33e DSFDWL ❑KITCHEN REMODEL
�VU Data CiaN pPP1.lANCES—RESIDLM'IAf. []ADDITION El PLUMBING RE-PIPE
Ir R W Data --Contractor
V1Qp. ❑MULTI-UNIT L3 STRUCTURAL
ARCI{ITECTS DECLARATION
p,pm i'ANF.LS MODIFICATION
Z Oy? IundersmnJ my plans shallbeused tee public records
Oz„� UP T02W AMP$ El INTERIOR [I CHIMNEY REPAIR
r;!,F'W Licensed Protevionnl 201-I001YAMI'S IMPROVEMENT E]SWIMMING POOLS
OWNER-IfUILOIiR DECLARATIONOVIiR 1000 AMPS D BATH RF.MODEUREPAIR EJ DEMOLITION
i O m
Q I hereby affirm that 1 am uxcmpa Inns the Contra mrs License law for the
U ❑OTHER
W p, fallowingream.Permit
]831.5, ..1tessand Prof de...xCalc:Any immenary SIGNS ELECTRICAL
W 3lL y which requires o permit to construct.otter improve,demollnh,our repair any xamnure
V,� prinnni¢issunnec,also remms the applicant fesuchp.it m lileasigned statement SPECIAL CIRCUIT''/MISC. oiv
F, r that he is licensed pursuant as the provisions of the Contractors License Law(Chapter 9
COMMERCIAL
WCC TEMP.MrFER OR POLE INST.
d y o C that he is exempt therefrom and the basis for the allegnl exemption.Any violation of ❑NEW BLDG/ADDITION El DEMOLITION
LLXl WN Section711315 by anyupplimnt fain permit subjects theapplicam transit peneltyof POWER DEVICES
[I TENANT ❑FOOD SERVICE
and mare than live hundred dollars(55nm,
FZC E)I,usownerof the prnpeny,our my mnployc,s with wages,,,their Bole camp,nmtian, 5 MMING POOL ELECTRIC DOTH RVEMENT'
F. will do the work,and thesuucure is nm intended or offered for sale(See7044,Business
6'3 and Prafesuiom Cale:The Contractor's Licen.w Law does me apply ur an owner of UT..:I:S—$WITCHES-19XTlIRES
property who builds or improves thereon.and who discs such work himself at hrough
his own employees,provided that such improvements ore not intended ter offered for E IUIiNFIN.ELECTR SQ FI'.
,de.IL however the building or improvement is.wld within nae year of..... ainv,the SQ.VL FLOOR ARBA VSQ,FT,
er-builder will have the burden of proving that he did not build or improve for pur-
ryax of sam).
TOTAL:
1,as owner of alae property,me xclusively contracting with licensed commelors to
consume the project(Sec.71144.Business and Professions Cade:)The Cnntrvcmr's Li-
censeLaw does not apply to Eisner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a cnmrumngs)licensed pursuant to the Commeurs
Licwnw law. PERMIT ISSUANCE
DlomexanmtunderSec. ,B&PCfmthixreaxon
ALTI?R-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
• WORKER'S COMPENSATION DECWRATate BACK FLOW PROTF.CI'.DEVICE: L 0
1 hereby affirm under penalty of pejvey one of the fallowing declurrawme A
❑Ihave unJ will maimainaCcnife:nc of CnnsennnsdGin.wrtfor Workers Cnmpen- DRAINS—FLOOR,ROOPAREACOND. STQ 'TYPE CONSTRUCTION
sation,as provided for by Section 3]8(1 of the Labor Code,for the performance of the
work for which this pmarmi is issued. PIX'I URES—PER'[RAP
I have and will maintain Workers Compcawaion Insurance,u,required by Section
3]ll0 n(thc Lahr Code,(tithe pcdnrmantt ol'tim work lm which this pcmtit is issued. GAS—EA.SYS'fEM-I INC.60lIT1.BL5 OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number arc.
Carrier: Policy No.: GAS—FA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASIIINUUSTRI.WASTE IN'fERCE190N
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section noel nm be completadfits,permile,foram,hundred dollars.(SILO) GRFASETRAP
or less) PLANCI IECK PEE
I cenify that in ere perfnr anceol'the work for which this pemtia is ixsueJ,lshall SEWER—SANITARY—STORM EA.1(M)IT.
not employ, y ronin any a 1n Mcmme subject mtM Workcri Camper- ENERGYI'EE
moron a sdj omnia. c WATTRHEATERWNENT/ELF.CI'R
Applin "� GRADING FI?E
y Ndfl ( APPLidi :IL ager making this Cenificae of Exemption,yon should WATER SYSTIiMTREATING
I" become subject to the Workers Cam ,,tion ns of the Labour Cade,you must SOILS FEE
pent p.it si
forthwith comply with such provisions our this permit shallbeJamed revoke]. WATEN SERVICIi
Q
CONsi-RuCiONLENDINGAGFNCV NIiW RESIDLMIIAL PLMB. SQ.FT. PAID
U 0 I herebyaffinn thea there iso connotation lending agency fnnhe performance of a [material III
Us 1^ the work for which this pernia is issued(Sec.3099.Co.C.)
U Lender's Name
O TOTAL:
0 U lsndm'x Address TALI '
i. yI comity that 1 have mad this application and state that the above information is BUILDING PEG e
iFi fA mesa.l agree m comply with all city and county ordinances and some laws rclntingro QTY. MECtiANICAI.PERMIT FEE
U building construction,and hereby authorimra,m cnmtives of this city m enter upon the SEISMIC FEE
above-mentioned property for inapeeiun purpnscs. PERMIT ISSUANCE
ELECTRIC PF.E
(We)agree to save,indent and keep harmless the City of Cup,nino against
Iinbilities,judgments,costs and expenses which may in any way accrue against said City ALTER D'1'O MP. PLUMBING M717
in one......ce of the gmming of in a permit.
AVPL1 UNDERSTA �11-1-COMPLY WITH ALL NON-POINT AIR HA 1 r UNI r011. CFM MECHANICAL FEE
SOU ERE IULATION
AIR IIAN .0 E If I CONS'I'RUC ION TAX
Sag ph I/Communr Dam F,XHAUS DOD( /DUCT) HOUSING MITIGATION IEE
HAZARDOUS MATERIALS DISCLOSURE
Will theft plicant or furor,building occupant store our handle hazardous material IfEAGN UNI'1'(TO 100NMBTU)
as defined io the Cupcnino Municipal Code,Chapter 9.12,anA the Health and Safety
Cale,Senior 255J2(a)a IB?ATING U 'Y
❑Yes E]N. VEN'f1LAT1ONFAN(SINGLIi RES PAID Data RaeiptIt
• Will the upplicam or future building occupant use Winpment or devices which BOILER—COMP GHP OR 1(10,(1011 BTU)
emit Intend.,an conmmin:mts ns def red
by the Bay Area Air Quality Management TOTAL:
DtsmatR BOILER—COMP(OVER 100,000BTU)
F)Yes DNo
I have mad the hamrdous materials requirements under Chapter 6.95 of the Cali.. AIR CONDITIONER JSSCANCF DAT
fomite f{mlO&Safety Cale,&,tions 25505,25533 and 25534.1 undmsmnd ohm if the NEW RESIDENTIAL MECH. SQ,FL 111 ` Q
building does not currently have o tenant,that it is my responsibility se notify the oecepam G'
of the m,mremams which muBt be met pilar to I,,..ml a Car iGewr of Occupancy. I
Owner or amhnrinal agent Dam TOTAL: I ISSUED BY: `-�
OFFICE