S 0559 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY \
CITYOFCUI'ERTINO BUILDING-ELEC`T'RICAL PERMIT NO.
BUILDING DIVISION APPLICATIONWERMIT I'LUD1xINf..MF.cIIArvlCn1. r. 0559 5 n
BUILDING PROJECT IDENTIFICATION J J J
BUILDING ADDRESS,. SANITARY NO. APPLICATION SUBVI TIAL UNIT
lD Aq'eAL6ONtE
UW L SNAME /� PHONE OSBACTOR:S NAME: LIC NU:
NIC 'ONIItOLM
Eb 4-
ARCHITECT NGIN'� LIC NO: ADDRESS: - ❑ �
CONTACT PHONE: BUILDING PERMIT INFO
❑ Co u pant Fees Paid by Applicant(Initial) HIDG ffl= I' UM MECH
�7-alas El ❑
UCENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
I herthy alram that I mer heemed ttae pnvlainn of chalRer 9 6'ommaaciag JOB DESCRIPTION
wd'Z the Iim]I>tnlnt DMO oro l ofdb ea.iie vrd Plot,—Coe.sand my lice.is RESIDENTIAL
F�� in wt full forte and effect PERMITISSUANCF.
wF�.uwEF�,t Liccnw Cltom Lic 11 ❑SFDWL ❑KITCHFN REM(IDlil.
<Q- Dart Caurecur APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBINGRESPIPB
ANCFII'I'IiCI'S DLCIARA9'ION ❑MULTI-UNff ❑S9RUCNRAL
PANELS
Z Z Z 1 araC card mY PI^n,^hell be wN a*WI'lie e¢ad` MODIFlCATION
O � UP 21M1AMP$ ❑I ERIOR� 13 Cl IIMNEY REPAIR
L'scn Prof.lovl 281-1000AMPS LNPROVESIFW ElSWIMMING POOLS
may$; OWNIR-BUILDER DECLARATION 0y1;µltxp,\MI'S ❑HATH HIMODEIAEPNR ❑DEMOLI'I'[ON
1'uudd''6 I hereby affmt that I am e.ampt Gmm the Conuvetnr'x Licen¢I'w fur the
fix'b 1 U fnllowin8 ieavtn.(Satiw]8113.Nu`iiaeu e4 Pmfesuan Code:AnY ciUY or ewmy' SIGNS ELECTRICAL ❑OTHER
1+131L E' which rc,aita a,canna to coax,ra,,alter,i.,aorr,do—W,or,coir any aructov
puntoit,issuuw .sa-rtyairts devpplicvµfar wch permit 10 Elea sired! 0., SPECIALCIRCUITMISC.
sss,�y Ibathei,liccm4purwannutbcpnvmoo,cOhcComtaaor'sLicenc,Ww(Oaaper9
o:p0 B,..nring wish Section 7000)of Divi.iun loftbe Blni.inild P4 easiuns Cooley w TEMP.ME`1ER OR POLE INST. COMMERCIAL
O.a e Unit he k exempt tMefmnt and the basis for the OlegM excmpion.Any viclmiw of ❑NEW BI.DCJAED1TION ❑DEMOLITION
k m_li Scaim]ID1.5 by son, ,I'..t for.Pcmlil-lij¢u tlr al'liwnn a civil pemlry of POWER DEVICES
H rax more than flit hundred dollen($.W). TENANT FWD SERVICE
IMPROVEMENT
wpdQ do,arwncr .aha the st yarany intended wilhwngerar,,le raxle (W,Btowion, SWIMMING POOL L'LIiCI'HIC
+�+F.. wall dothcvmt.Cd :T e m mwaocimcMMnr w docs not
rily loan
—per of OTHER
13m v4 Pmy abi,b C4c:TM1cove,fxiNs Lnd w Ivw dwc mer rk hi inlf cithro of OII'II.LTS-SW'ITCIIIS-11%TIIRES
pail.whp builds err ivadW co lh tach ,and who doe,such work dcad o r of thmugh
anIf. ampMryeehe Nildi al oral Mac ioart is rcntx on.nm inlcnJcd an offered for NEW RF_SIIIEKIIAL EI.ECTR SQ FT.
sdc.If.haiwevcr,rhe Jing orimpmvenent is wd wiid run rdde icompiniw,Ultc SQ fT.FLUOR AREA 5/SQ.IT.
vwxr-huile.f will rare the burden of,carving that he did amt IuiIJ w impovc fm par- U6 14
of,fl
M the poper,em.,iaO,i,ad ewinetivg with 1lmmcd OIWIlar,io TOTAL' CITY
MUGU
nese Lo ora pnijmi(Sm.]1114.Haler of and I'ndu,siwn is l Tim Co ihec ,Li- y�l L
sclswclsfraa.PMYto e%,th aoflnwenywlnbuildPu mints Drover.sad QTY. PLUMBING PERMIT FEE Ufa �urck r1N
whonsc"w.,far,uch project.witM1 n ewtmaMs)licensed purwent to tM1e CmtrvenM, Q
Liccnm Ww.
BG PCfor this re.wn PERMIT ISSUANCE
slam under Sec. ,
D.re ALTER-DRAIN&VENT-WATER(EA) VALUATION
Oxx
W KER'S COMPP SATION MCI ARATION BACK FLOW PRCIIELT.DEVICE
(48, heI have reby Uflion seder penalty ,M pt,.,me of the ficit ing dc,isomom:
rj end will mai main.Cm dime M Comma to¢IGinmr,for Woricr,Cooper- DRAINS-FLUOR.ROOF.A R Ek,CON D, STORIES TY PE CONSTR ULTION
cion,us poi ided fart by Section 17W M the Labor C4c,for the Orfmntatre of Ire
wok for which this .it is i.and. F XTURIS-PER TRAP
❑ I have wJ will mainmin Wodch CooipaLsmion Inmrarcq at rtyuir d by Section
1]()0oft1bc laMrCude,forUhe perf.nce afdicwok for,,bicb ON,p.it is i.weE. GAS-EA.SYSTEM-I INCA OIITIJ:IS (KC.CROUP APN
My Work-0 Coa,r,lion In.rurvrce ericaand Puliay mambcr art:
C�nicc Policy No: GAS-EA.SYS W-OVFA 4(EA)
CERPIF]CATF.OIr EXFMMON FROM WORKERS'
COMPENSATION INSURANCE GREASF/INDUSIRL WASTE IM'ERCEf OR
BUILDING DIVISION PEPS
rend rot completed!(Thi,wmim t he pleted iftk Parr it is fora hundred Mllwn(SIW) GREASF.TRAP
or Icre.l PfANC11ECK It'F,
I certify Uha in the prfnrm.rcc of lac rvork forwhich Nis permit L,Inwd,I.hell SEWER-SANITARY-STORM EA.2W IT
nal employ any piwm in any nwnna rn ar to hreumc,oby.Yt m the Wrckcrn'Cnmpcm ENERGY FEE
zz netiw Laws of Cbl fmli..Datc WATER HEATER W'NINVELEC
Applicant GRADING FEIi
y
NOTICE TO APPLICANT:If,after making this Cendiezoe of E,can" n,yavr:herald WATER SYSTFJSIIT TING
become sabjmU to the Worker,Cumpco,niw pocvisi M the IVMx Cole,yw mast SOUS FI:I?
1= forthwith cwiply vt1b eaten onciu.,or,hk finan,s ll be,dcemeJ revW4. WATER SERVICE
M
oz CONSTRUCTION I.DSDING AGENCY NEW RESIDFNI'IAL PI-MB SQ.Fr. AID Dt
Ilertby air thu Uh<rtis.arutructian Ending vgrnry Rx Uhc pHmimrim of cagd
C.7 0Uha woo,forwhicr obi,p nit i,issued(S,,.11H],Civ.C.)
Oleader'`Nome fDTA 1.
V 1<iber,Adds, NVII
0. 1 cmify,Mt I lwve iced Uhi,ap,lkatiort and same than the.lane inGamurion is - BU1LIlIN F
t,, correct.)Ugrm to comply with all city rand!manly ordin.nm and we law,relating. QTY, MECHANICAL PERMIT EEF-
U � hnidinpewclnatinn,and M1crdiya.oIho, ayrermtativc,aOhi,city o enmrupm floe SEISMICP
shove-memioaeJ pgx ny fax irm action pmpee.. PERMIT ISSUANCE
(Wc)agrm m wsc,indemnify aM kap ha mk s tM Clly of Cupatim againa ELECTRIC il?
IieMlitie,judgmcnn.emu v4 cxpn.c,which rimy in any way acerae egeimUraid CiD ALTPA OR ADD TOMECH.in
wm of 11n,granting mfthis pnnii, PLUb1B1 FEE
API-1 . T UNDERSTANDS AND WILL COMPLY WITH ALL NON AIR HANDLING UNIT(TO 10,008 CFM)
A1ECH ICAL
FEE
�'
50 CE EGULATIONS,
a 7"" AIR HANDLING UNIT(OVER 10.000 CFM) Cf INSTRU NTAX
"C
ger co(Applittnjl atom, Unit,
/e BXI{AUSI'PIIX)D(WIUUCI') HOUSING MHIGA NFTIi
6 nDOUS MATI:RIAIS DISCLOSURE
Will tfe iu,lw-a w Tamm building..past More car handle haevnlna,material IIIi TI NO UNIT(TO IW,"BTU)
as Jell vol by 11e Cupcniw Municipal CoM,Chapter Y,12,04 dm Ilealth and Safety
Code,Section 2551200? HEATING UNIT(OVFR 1W.000 BTU)
❑Ya ❑No VENT]CATION FAN(SINGLE RES 1111 PAID
WJI the aPplimnt tr latarc hoilding occupant aaw aluipnenl ur davic�� which Daoe Rcccip N
caril hnau %air conLNancous ea JeEaa4 by the BUY Arta Air Qu itr Merlagemrni BOILER-COMP LOP OR ION)."HN) TlyfAl.:
Dwric,❑Yes [:]No
! BOILER-COMP(OVER INMW B'I'U)
I have revel die 1w.atd u,mmerna,rtyoiaenomn mdm Cha au 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
frrvia HoIth A Safety Code.Scaiars 33(15.25511.4255}1.l uivknwd aha if the NEW RESIDMKTAL MECH. SQ.FT.
building Mrs no,cuvently have ocomm,ft io many re s-ilaMyto omfy are avupmt
of de re,c,u'uenrn.`which mux be met pro On i,wuam of.CmiOom of Occuparcy.
(Owrer a audwrired agem Dom TOfAI-: ISSUED H ''
OFFICE