27202 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPESRTINO BUILD
ING-ELFT TRICAL PERMIT NO.
APPLICATION/PERMIT PLUMBNG-MECHANICAL T IDF] n e�O e�
BUILDING DIVISION BUILDING PROJECNI IF'ICAI]ON L L G
BUILDING ADDRESS: SANITARY NO. AMICATTONSUBMIITALDATE
lefz-6.5—
UNIT# LOT#
OWNIi1pG1yA.m, g E: CO ACTOR'S AME:
�/.[(�.�--.aV.1/ rVI
NICT CONTROL q
ARCIi1TECT/EN :ER: LIC NO: ADDRESS: ❑
!/ , /�Q U,
CON ACo: PHONE: !�j//` QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
17 �� 2�j!/ T7-5 B E I:CI' PLUMB MECII
/� �✓'� 1 PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
pcitZ IM1erchy affirm that l am licensed underprovisions of Cbapmo9(commencingwith JOB DESCRIPTION
FOO Section 7")of Division 3 critic Business and Professions Code.and my license is in
PANELS
gutfull!once and effen.
FZw Licca.Clens Lie# UPT0200AMPS-
,n?y Dam Conwcmr 201-Ig10 AMPS �I
ZOy7 ARC]IDECT'S DECLARATION OVER 1000 AMPS SQ.fit.FLOOR AREA $/SQ.ET.
O Z L O 1 understand my plans shall be used as public records, `
I-LC� SIGNS ELECTRICAL t, _, aw /�#
-K[Y2.'.II LicemeJ Pnslbxsional {*r�t��t,,a
K
�< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
�d�((OaF 1 hereby affirm that I am exempt from the Contractor's License Law for the
follow413{Lm whichingremnaermittoconstrut,her, andimprove.
Profusions Code:Any city stcounty l'EMP.METER OR POLEINST.
F a"; which requires n permit,o construct, her,improve,h drowhsh,m apair any snucmre
�uNu11}5 ththnslts icensedaaksuntto the lhevisicamfor the Co Permit Licele a se La statement POWER DEVICES
,0 C
that he is licensed pursuant m the provisions of the Contractor's License Law(Chapter
ati C 9 'N Section Division 3 of the Business and Professions Code SWIMMING POOL ELECTRIC
KOLL (commencing w+ ) VALUATION
tp -y or thus he is exempt therefrom and the basis for lheallefei exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
FZ_a Section 7031.5 by any applicant for a permit subjects the applicat
n .a civil penalty of IL i
not mom than five hundred dollars(5500).
K � ❑ I,asownernf,hepropeny.arm Io ecswiPwa esus lhcinolecom NEW RF:SIDFNTIAI.ELGCI'It _SQ.FT.
YanP Y b pcnsmi.n, S'1'OR 8 TYPE CONSTRUCTION
awill Jo the work.and the structures is not intended oroffcamd ,Business
and Professions Cafe:The Camosewn's License Law d t apply to an wneo of
property whohuildsorimprovcx thereon,and whodoesyya kbimmll'or throw hIms
employees.provided that suchimprovements of imembaloraffered fors] f, OCC.GROUP RFS.UNIT'S
however.the building or improvement is oldr�in one year of completion,Mc came T �.
builder will have the FurJcn of pruning lh Ii did not build or improve for purpose of
sake.). /y
❑ Lasownernf thepropeny,am caF lusivdyconva<ting withlicen conmiclo, PIrlY, PLUMBING PERMIT FEE FLOOUZONE APN
conn,,the project(Sec.A orwm it Profesim,Code: s Conrado
License Law ocsnot apply tw erofpropenywhobuil s#r9lt nes therco�y 'RMIT ISSUANCE
who eommeufi+rsuch pmje swi,hacommttoKs)licensed oche Contrfrtlks AER (EA)
Liecom Law. vv `` ( FEE SUMMARY
❑ I em exempt under c. &P C r Ndmason BACK FLAW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN_
Owner Dam DRAINS-FLOOR,ROOF.AREA,COND. RECEIPTN
co WORKMA COMPE Sc DELLA TIQN SCHOOLTAX YN
❑ Ihemhy off rat that lM1se,1 enifie cat 0" d tifcateo RECEIPT#
Wrokeri Compensation Insurance ecenifie o FIXTURES TRAP PARK FEE Y N
rsell employeesunder thispeem; op ,here. es]800,LabCJwh' �#
Policy# GAS-F.A.SYSTGM-1 INC.40U $ BUILD DTVI FEES
Company GAS-EA.SYSTEM-OVF. (LA) PLANCHGCK FEE
���❑//////Certified copy is hereby famished. VS
CctiOcd copy is filed with the city inspen; division. GREASE([NDUSTR ASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF E%EMPTION FR WORKERS' GREASE:TRA SOILS FEE
COMPENSATION INSURA
('this section need not becompleted iritic pnmi,is Toro dollars($100) SEWER. gNITARY STORM EA.2(gFf. UNE
or less.)
(unify lhm in the performance of the work forwhich this permit is issued,lshakl WA ,R HEATER W/VENT/ELECIR
not employ any person in any mammy so as to become subject t.the Workers'
PAID
z Compensation laws of CBlifnmia. Date ATER SYSTEM/IRPATINGt Receipt#
z O NOTIAppliCE
NOTICE TOAPPLICANT:IL after Compensation
this Certificate hExemption,you should mind NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
F > h,camcsubjedy warn
f ,Compensation prmit hailtftheemed Code youmust
lotthwilh comply with such provisions.nhis permit shall be Deemed revoked. BUILDING FEE
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z 1 hereby affirm that them is a construction lending agency for the performance of
U Q he work for which this permit is issued(See3097,CO.C.) TOTAL: ELECTRIC
I.cnder's Nam,
Q U [Lader',Address QTY. MECHANICAL PERMIT FEE PLUMBIN FE
1 certify that 1 have read this application and sate the,the above information rs
cones. Ingrre in comply with all city and county ordinances and state lows reading to PERMIT ISSUANCE MECHANIC .FEE
buildingconsnactl.a,and hereby Bathroom repmsentativesofthis city to enter upon tBe
U z above mentioned property for inspection purposes. ALTF,RORADDTOMECH" CONSTRU ON TAX
(We)agree ,,save,indemnify and keep harmless the City of Curenlno against
Iiabilitics,pal,wim,rrusend expenses which may in any wayacrne against said City AIR HANDLING UNIT ITO IO,000C
uenhe gmmi; +(this pcmtit
AIR HANDLING UNIT(OVER CFM)
amr of Applicant/ onto' o Out EXHAUST HOOD(W/D )
PAID
H ",ARDOU MAgOccupSDISCIASURE IIEATING UNIT(T 0aRMID)
D c Be
Will the the Clam oro ture Municipal
Ci Occupant C a p err,or handle h;verdoanmaterial
as define]by the Cupcnino Municipal Code,Chapter 9.12,and the Health and Safety ZBOI -
(OVER
Code,Section 25532(.)1
11 Yes 1:1 NO PAN(SI
Will the applicant
some nmr fumrcbuilding occupant um equipmentnrdevices which emit
E OHP OSUANC ATE
.�hiumel.x air ummminonis es ddined by the Buy Arcu Air Qunliry Management P OVERDlsWcf! ( '
❑Yes ❑No NEW RESIDENTIAL MLC(I. SQ.FT. /�p
1 have read the haommums materials requimments under Chapter 6.95 of the ■Jt!)�
Califomia llenhh&Safety Code,Sections 25505.25533 and 25534. 1 understand that `��FN► 1�
if the building docs not currently have a tenant,that it is my responsibility,.notify the W7.
it I V
occupant of the requirements which must he me,prior to issuance of a Certificate of V
Occupancy. U."
is or vuthovcd agent Dam
TOTAL: ISSUED BY:
OFFICE