S 2645 APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES,-USE BALL POINT PEN ONLY
CITY OF CUPI$RTINO BUILDING-F.LEC'I'RICA L PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 2645
VIII LDING.PROJECT IDEN'TIFICNI'ION
BUILDINGADDREYS: SANITARY NO. APPLICATION SUBM1"P[AT,DATE
Z^ Q
OW R'S NAM PHONE. COM Ci B'. N ME: LIC NO: ^
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A TI ]IN(i1N1iL'k: V 1 O ADIINISS: ❑ V
CC N'1 CC: O PHONE: BUILDINGPERMITINPO'
❑ Consultant Fees Paid by Applicant(Initial) RLDG ELECT PLUhtlt MI?CII
l� (ASO er
LICEN.SIB)CONT CfOR'S D.CLARATI( Q'pY. - ELECTRIC PERMITMatz
Flit.
leery anion that I am licem d under pct isions of Ch mar 9 mannowneing JOB DESCRIPTION
'C' whb$ealin i 9fxW)nl Dlvixinn Sul Ie Businmsand Prnl'essians Caw't lot,licemc is ' RESIDENTIAL'
Op I'IRMITISSIIANCE $
F Wn Infull Eac.andaftecl. ❑SFDWL ❑KHCHFN RHMODRI.
�UU License Clan Lw.K AI'I'LIANCI?5-RESIDENI'IAI. ❑MDITION 0 PLUMBING ITR PIPE
mZ a Dwc Cnmrvctor
4 I' .ITHiCI"S DECLARATION El MULTI-UNIT 0SI'RUCTURN.
F,7m 1'AN1il.5 MODIFICATION
0 Z'4" ca a s (b used as public records
UI'TO 2 W AMPS
OZ�w ❑IN'f1iRI0R ❑Cf11MNl?Y REPAIR
F C�.�u] htcen o talesapma - 201-10(a)AMPS IMPROVEMENT []SWIMMINGPOOIti
OWN t-BUILDER DECLAkAT10N OVER 1000AMPS ❑BATH REMODEUREPAIR ❑UEMOLI'DON
QEc)w hereby affirm Thal I am exempt from the Contractor's License law for the
IrKj 3 c.E following motion.(Section 9031.5,Bmineas and Pietism...Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
m which requires o permit m construct,inter,improve,demolish,or repair any strunoc
Fv-0:5 prior nn its issuance.also requires the applicant for such psrni In file a ,sacti,mtentcan SPECIAL CIRCUI'T/MISC. -
f�y that he is licensed pursunat in the provisions of the Contractors License Law(Chapter 9
sit 0 (commencing with Section 7000)of Division 3 ofthe Business and profession.Cnle)or TI?M R MlOHR OR POLE,INST. COMMERCIAL:
dX e (hut he is exempt theretmm and the basis for the alleged ola
exemption.Any vition of ❑NEW BLDGIADDITION [I DEMOLITION
Section 1031.5 by any ap,licunl fin,.Pernod,subjeeni the applicant In a civil Penaltyof POWER DEVICES FNANT ❑FOOD SERVICE
^Z not more than five hunddeddolloa($5011). PROVEMENT
W
SQ Las owner ul the pmpeny,nr my employees with wages as their sole compenvfinn, SWIMMING POOL ELECTRIC
p.0 will do tho
e wk.and Oto sIinciam is ant intended or oRered for wle(See,7014,13 usines.s ❑OTHER
W 3 m and Pr.fcssions Cole:I'he CDmme.r's License Taw does not apply m oo
n wner ul" IITLI TS-SWITCHES-FIX'1'ORES
a' prnpany who bar,],.,,improves thereon,and who does such wad himself.,through
his own employees,provided Ihm such impmvemim s arc net intended or olfcred Lor NEW RESIDENTIAL ELF.CTR SQ IT.
rdo.IL hnwevc0 the I ilding.r improvement ie hold within oneycarofetonpletion,the SQ.FC.FLOOR AREA $XQ.PI'.
cr"huildcr will bmc the Widen of proving that he did not build or improve for PUT-
pose
us- .//��
❑po tL as ow.). - '1.0� L' �� �1
Las owucr of the prulteny,nm cnduaivrlY mnbacting with Ilcewal nmmemrs m 1 lo
i4 the project(Sea 9044.Buainew and Pmfassicns Codec.)The Cmuunauu,Li-
xeLow does not applytoannwnet ofpmpenywho buildsorimproves thereon,rand QTY. PL1 GING PERMIT FEE
wb...... sfhenuch Mnjms with aenmmctngc)IirensrA pursunmmthe Cnntmanra
Licence Law. - PERMTT ISSUAN E
I am exempt under See. ,B&P C for this reason
ALT(?R-DRAL & 'ENT-WATER(EA) VALUATION
Owner Dutra
WORKER'S COMPENSATION DECLARATION HACK FLOW PROT B
• Ihereby uffirm under Penalty of perjury one of the following declarations: (f V
I have and will mainmin is Cenificate of Camentto self-insure for Workers Compen- DRAINS-FLOOR,ROO. STORIES TYPE CONSTRUCT ION
ration,as pmvidcd for by Section 37M of the labor Code,for the performance of the
work for which this ,rousit is issued. I'IXTORES-PER TRAP, Uv
Q I have end will maimain Workers Compensation Ineumnce,as"Weed by Seetinn
3900 nfum labor Code,for theperformrrac ofthe work for which this permit is issued. GAS-EA.SYSTEM-II 'JOU .GTS OCC.GROUP AI'N
My Wnrkrr'sC.minnmtion Estimate cmnerand Policy mariner ate: PN
Carrier. Policy No.: GAS-FA.SYSTEM-OVER 4I- ` b
97>
CEM IIICATG OF 1?XEMPIION FROM WORKERS' GRI?ASF/INDUSTRL WASTE INTBRCIiPI'ON O
COMPENSATION INSURANCE BUILDING DIVISION IT GS_
(Thlsmetin i need nm beeamplead ifthepermit i.sfuronehundreddohmsl$RIO) GR1iAS1?T
or less.) PLANCHECKFEE 9r.,se O
IeUrby thin in lino penipnumec nflhc work fix which lh6panut is issvcd,lshall SEWER- J ARY BA.2181 r1
11111 antploy tory,......in nay manner so ns In me tesuhlcet to the Workers C11mpctt. IiNP.l2GV FEE ( 6
O N(on Lows of Gllfnnn't'Dao WR'I'ER ATnR WIVEMC/ELIiCflt
to
7 Applin 111 f - GRADING PER
`� orae s TO subject
to the Work IL aloin punkin n r Certificate of of PLatn lion,you should g P WA1'IiR TIiM N SOILS PE
[
become xuhjcct m the Wurkcry Compensation provision.of the Labor Code,you mull '
forthwith aamply all such provisions on,this paddit shall he deentedrevaked. WATHR ERVICF.
Q
z CONSTRUCTION LENDING AG17NCY NEW [. �tls'T1AL PLMR. SQ.P. PAID
U 0 Thereby infirm thanhert is aconemction[commitment,for the perinrmunce of a¢ Hecaptp
the work for which this pcmtit is issued(Sec.3097.Civ.C.)
TL F" Lender's Name TOTAL:
U 1<nder's Add ren> 'TOTAL.:
r lLl 1 ttnify that I have mad This application and state Ihm the ab.ve informed..is RU V FEE
Ftt,l correct.l agree to comply with all city and county ordinances a ad cote laws belminget Q'T'Y. MECHANICAL PERMIT ITE SETS FEE
U z Wildingcon.nructinn.ond hereby uuthmim represenotives of this city to rnmrupm the Z
absvcmentioned Mopcny for inspection purposes. PERMIT ISSUANCE O
(We)agree u,sa.e,indemnify and keep hanin
harmless the City of Culno against ELE 1C[ZEE 2 . 3 0
liabilities,judgments,costs and expenses which may in any way wenum Utmost said City ALIHE OR A DO TO MECIL
nsequcnceofthegmnfi 'of this permit PLUM NG IEE
APPI.IC UNI AIR HANDLING UNIT(TO 10.06 M)ST I. AND WILL COMPLY WITH AL1. ON-POINT
IT MECHAN LPEB
SOURr': lif Il )' -r ?
p � AIR HANDLING UNIT(OVER I0.010 CIrM) CONSTRUCTION TAX
. g ddpplmae/Cnnmm r - J 1 I?%I IAOS'fII00D(W/DUC'q
IIAZAItI OUSMAI'FRIALSDISCL05 RE HOOFING MITIGATION THEn:n r
III @c upPllcum ur fl um hullJing occupant eanrc ar honJla bverinux mumriul III?ATINGUNI100100,0001H"U)
as defined by(ha Cape I Munici I Code,Chapter 912.and the Health tad Snfcty
Code,Sccdon 25532LIi I I??ATINC,UNIT(OVER I about)RTU)
❑Ym No - VEN'TILATIONFAN(SINGLERESIDI PAID Date ReeciplM
Intrll oduce,
an cortluornature(wilding by ueBuse ea Air uardeviceswhich BOILER-COMP(3HP OR IOO.001)BTU)
emit District
s us air cnneminun defised by Ne Pay Arca Air Qualify Management OT
DiarinP
❑Yeti Fl No BOILER-COMP(OVER 100,000 PTU)
AIR CONDITIONER
Lave rtml the her Jnu.v maoriols requirttnenu under Charter 6.95 al Ibe Cali" ISSUANCE DATE
forms 11 ti�Ii.. 25505.is 533 anyand25534.'j'at1 undenondtatifthe NEW HFSIDEMIIALMECFI. SQ.17. 1
buildi nen it t c n atencipstaI. lticmy cufacilityu ofify the ccurym
nn pnnrminsuance nfuC ifi tc nf^(1kc I
Ow uthor d.'roto ZZ um AL: ISSUED BY: Q
OFFICE