S 2463APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUI'ERTINO BUILDING - RLELTRTC\L PERMIT NO.
RUH,DING DIVISION APPLICATION/PERMIT PING PR c - MEOHNIIFIC S 2463
Ruu.uwr. PunIRIT mRNru'IornuN
1.LO.
LICENSED CONTRACTOR'S DECCAR TIO
I Mmhy ufnnn ma I an nanwd ander rywi,ians of Cosimer 9 (rnmmeneing
wllh Actirn 90018 oflyivl,wn 3 0l Ae llu,incw aul Padesatru Corte, and my beense u
in full fora and effcn.
frac Clun Lich
FSH
ARCHITECT'S DECI,ARAFION
z 0 n 7j- I untknand Iny plan, xhull ho uwd a publ'e arewd,
OG O
p N F W I hei PrafeVoonat
❑ Consultant Fees Paid by Applicant (Initial)
,TY ELECTRIC PERMIT FEE
PERMIT ISSUANCE
APPLIANCES - RPSIDEATAL
PANELS
UPTO2WAMPS
nd,YE� OWNER-HUILDER DEiC1ARAl'ION
C C 6 1 b,ehy u1BmI it., I tan c,,an, fent Shu Coale ctw', Licenw Lw fur the
k O S U hAlaw ng rw
n a u (Semite )1019, Hasinand Ptafes,ira, Coor la: Nry ciy ary
If] 31i. which tcgbina Permit to conNlvct. slier,siipmve, demo irh, or repair any structure
F ��S pritxm lDosua:ne.nI- tryuimsthe vWii,. far xuch Permian Plc o UgnW yatrnmrn
f } that he 1, lXeric p.—nna lhepmvisitxu oflhe Coa,.,c,', Liana, law(Chapcf9
W C O O Icvmmcnciag wilh Sectian 7000),)t ITY-to 3 of the laaalae, and ProfcxiensCatle), r
m d e C that be ix exempt Innefnlm not tM ba iA f the all,ed e, a n,ion, Any eiuluda. of
NSwTlsm %0113 by any .,]it. fp a pemul whjeet, are, ePplicanl to a evil penally of
F^zQm Inure Uum five haadd &H. (SA0).
OLm:wneraflw pnryenY, nr lay cnlpluyrc aim at mtheiramR nxnpencYnln
'teZ0 wllldotk work. end the,wnute is nm imm�deJ traPwwl forwlc lSmJ('AJ, Ilu,ines
P] 3 and 2eitiama Ctdc The Cmtmcar, Lleeew Law deco not v,Iy u, as twrer of
pngeny who huilE, orinllnovc, merx , and xM, are, wch work hitmclf w thmuwM1
his awn provilW that wch Impmva seri are 011 meedul to, ofcrtd fm
tde.If. how r. tiro hadding (,r rope Inti, cold within our yafofcm,nRtitm.tle
Darer -Walter wit hive the buten of Ixoving that he did not hwld tr impnrvc La pur-
Inw at side.).
tJrs110 al the pmlen, am crclualvely cwlraclin6 with licensed
,named the project fSce. 911IJ, i'nllca n, Calcp The Ctrnnv:etlxtof7lli,r d
calaelawJaaemts,P, -
QTY.
Liwe canlaaf6 far each prujmis aim v I:ontrvntr(s) IiccnwA par,uannn IM1c Gmlmcen'n
Liana law.
Imo comp urlJter SL'. .P&YCfair mi, rtawn
—,Yl n,��
W'ORKIPRAUON DECIARDECIARATION�
I badly1llanal slitter pctmlty lcoWenerneofthefollowingtkclar',Co
er,,c and wills for-
uCmi Sala of Conwnlmcw,L ONperfdatitofen-
aiom, a, pr rviMl , by Scotian 37I0 tribe Lobr Gvlc, f e the prgnluwme a lM
ni far which B primal is d.
❑ have and will Isla, of be doe Compemvian Irkfor a, le rtquirN by Sectitm
MyWeer'3700 fithe Cor Ca,almrhepe omutleer ata olie ftcwhiehe. pemlit isisuled.
Myler, re Comlamatitm lnwmnro carrier and! Hdiryn InM1cr vm:
Cortico TION Nm: u
CEKIIITCATEOFFSFIIONINS RAN WORKI3RS'
COMPENSATION INSURANCE
Tlhix aerate need nN hac(xnpluhd tflhc p-TI11I is fnr.re M1utldnddJWrs it IUII
aIc .)
1ovany Lha in inhe, paft Vomer attire wvk(tx wbicM1 mispernmd i.sl Coarsen
Tun cull of Iervan in aO' nvnner so a to bccnrte subjeel to the Wtxkclx' Cor11prv1
' O z wlinn lawn of California. Uum
Z O Applicant
rN-I NOTICE. TO APPLICANT: It, after coAing this Ccnificalc of Eacmplirn, you Trull
a breed., ,rbj", to be W'eler', Conpelnalstxl powisiom of the Ichor Code, you Imau
foMwi lift comply with x.h ptovisitm, or his pemul dull k deemul tvvaled.
G 0
.7. z CONSTRUCTION v,..,i LENDINGAGENCY
UO 1for haRithi that thtLi,ammtrle. 3,D .0, .) for IM1c perRxrlamcof
U.C L.I Ile work for which this permit i, iawd (,Sm. }09). civ. CJ
O U Lender', Aldo,
]y Item crI Adifyt
{ Zi 1 edify . 1 neve with
11 his vppncnleur yo Gala tool IAC nbow in elilinn ie
Z Initial ngreemmmply aim allciryand! wanlywdinatic6 ad aura la enter
the QTY.
U Z. huilding mnatucdtn. wd Mrin"'fr,"u'oe+cmotivo of mice city to enlm uryn IM1c
aMrv�. W )atnd pntpeny nor,antactitw punpmc,
(We)vgram save, ind.,rpea ndh,,h hn, in an IM1c City ru Cupcnin0id City
aa,aviraludgmtleearis ad4 this eerria, tlmyin any way acrnleagaillsl.aidCiry
nI CANT
title grunting tR This 1cmd1
SOURCE
RE ULATIO TANDS AN 1) WILL COMPLY WITH ALL NON -POINT
SOURCIi R[GUTATIONS. /
C
Signntun: ofA,la,rat/C.nlmcmt Dec
IIA%AROOU. MATERIALS DISCLOSURE,
Will the allpl'I eanl or future building treuponl more m hadlc hlvrvdtas nalerlal
C, okliteby Ih Cupmim Munaipal G.k, Clupter 9.1], nrd the Hohh nnA Safety
dc. Section 25534(0)?
❑Yc y�no
WdI the.,, Rea., or iodate huiding xerlkml ua cyuipnent or td,wi, which
it ~.,..Mous air rnu]minanla n defired by the Hay Area Air Quit try Managemcnl
DixvivlE
❑Yen XNo
1 baste rod the hnrmJnls.111ln taquir Nrhorder Chapter fi95ofIIF:Cal i-
famia I{cad & Safety Cade, Service, 255115. 25533 add 15504 1 utdmlmxl Elul if the
bu idillg des MI .,y b:1vc u emml, ma it is my Ie panaibilily to artily the accufwn
of the reruirenrnu whichaura he urn,,rar tea o. A a Cendleaa N Pcaw ..
:4
OVER I000AMPS
SIGNS ELECTRICAL
/-2f -9p 1
❑ ?1'3 --
BUILDING PERMIT IN
1'.LZ' PL ah
ELr
JOB DESCRIPTION
B171
SFUWI,
❑ KITCHEN REMODEL
❑ADDITION
❑PLUMBING RE -PIPE
0MULT'1-UNIT
❑NTRucrURN.
;W RESIDENTIAL ELECrR SQ FT
MODIFICATION
C3 INTERIOR
El CHIMNEY REPAIR
Ih(PROVENi EhT
C]SWIMMING POOIS
❑ BATH RENODEUREPAIR ❑DF_MOLRION
11 Orl{ER
ALTER - DRAIN&V
SPECIAL CIRCUIT/MISC.
BUILDING IT&U D
TEMP. METER OR POLE 1
COMMF,RCIAL'
El BLDG/ADDITION ❑DEMOLI'MON
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
POWER DIiVICES
SWIMMING POOL. ELECTRIC
OUTLETS -SWITCHES -FIXTURES
;W RESIDENTIAL ELECrR SQ FT
AIR H A LADLING UNIT LTO 10.000 CPMI
SQ.. FE FLOORAREASAQ.
(•�y1� /
IT
CONS'RUCTIQN'1'AS
FAA AUNT HOOD O"MUCTI
P BING PERMITFEE
PERMIT ISSU CI:
ALTER - DRAIN&V
'ATT:R (EA)
[7VALUATION
�O /
� 73
(�
BACK IE,OW PROTECT'. DEVICE
DRAINS -FLOOR, ROOF,AREA. COND.
STORIES
TYYF. CONSTRUCTION
FlXTURIS-PERTNAI'
GAS-EA.SYSTEM-IINCAOUTLETS
OCC. GROUT' APN
UI WG DIVISION VEES
GAS - EA. S1:STEN OVER J TEM
GREASE%INDUSTRI- WASTE INTERCEPTOR
GREASETRAP
_
YIANC IF.0 IEE
SEWER - SANITARY -STORh1EA20T FT.
ENENt 7 0
a
WATER HEATER W'NENTIELEC-IR
GRA t FEE
WATER SYS'ILMG`IUuVTING
SOLI_ liE
S
WATER SERVICE
PAID
Uatc Rn M "�
NEW RESIDENTIAL Pili SQ. PT.
BUILDING IT&U D
MECHANICAL PERMIT FEE
SEISAfIC
PERMIT ISSUANCE,
ELECT R ' E' . 2,
ALTER OR ADD TO MECH.
1'hUM1i HI IFIi
AIR H A LADLING UNIT LTO 10.000 CPMI
MIiC11ANIC. LIFE
AIR I IA N DIANG ON I r(ovER I o," CEM)
CONS'RUCTIQN'1'AS
FAA AUNT HOOD O"MUCTI
HOUSING MITIGATION FEE
I IFARNG UNIT OO 110,1101 BTU)
HGTING UNIT (OVER 100.000 RIM)
PAID
VEST LAI'ION FAN (SINGLE RESID)
Dale ku,,A C
BOILER —COMP OHI' OR 110,100 BTU)
TOTAL'
BOILER— COME (OVER 100.000 H'IU)
P
AIR CONDITIONER
ISSUANCE IJATIi
6�
ISSUED BY:
NEW R'LSIUEN'I'IAI. MECH. SQ Er.
3 f Ks o
a