S 0500 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPRRTINO BUII.DING-ELECTRICAL PERMIT NO:
CAU
BUILDING DIVISION APPLICATION/PERNi1T )LUMPING CT IDE NIFICA S 0500 500
ItUILU1N1:PROJECT IIIENTIFICATIUN V
BUILDING(UDRESS: SANITARY NO. TPI.ICATION SUBMITTAL DATE
�6� haw e ti r
OWNERS NAME: PHCIN{;; CONTT/RpvCr IC1R:S NA�1OI'A �` N I.IC N; NIC - CONTk(1I,p
S01' ail C ey'
• ARCHITECT/ENGINEER: LIC NO: - ADDRESS. ❑ .
�./OSr1r:�osP CONTACT. PHONE:�'1 PHONE: BUILDING PERMIT INFO
U / IA, a 9 �d-6 6 3 ❑ Consultant Fees Paid by Applicant(initial) Bhn ELECT PL�t MECH
r
'LICENS )CONTRACTOR'SDECLARATION QTY ELF,CTRIC PERMIT FEE
1 hereby off—dam 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
woo witA Sectinn]WO)of Division 3ofdm Busitmetuad Pndessinna Cnle,and ntylicense is RESIDENTIAL'
W O PERMIT ISSUANCE
FWB in full force and eB .4N ❑SPDWL ❑KI.UMRINREMODFF
�UF Liccnsc Clxs�I.ic,#�� e APPLIANCI!S-RITSIDfiNTIA1. ❑ADDITION - ❑PLUMBING RE-I'IPF
N uv�T" C'S DECIr /�TT
ARCHI'ffCIS❑ECLARATIO - ❑M111.T611NIT ❑MODIF'ICATIO
Z07�. UPT02 - MODIFICATION
vvJJ 1 understand my plans shall hs used as pubic records
Oz=JO uPT02(NIAMI'S El INTERIOR [I CHIMNEY RIiPAIR
W Licensed Professional 201.1000AMpS PROVEMENT E]SWIMMING POROUS
at Se S, OWNER BUILDBR DECLARATION
51Y a ac 1 hereby of.that I am exempt from the Comrnclnr's I.iceme Law for rhe OVER 1000AMPS Ili REMODEUREPAIR EIDEMOLITION
OF
K,3 a V fallowing reason.(Section 7031.5.Business and Professions Code:Any city of county SIGNS ELECTRICAL .R
W W which requires If mit perm conamm,alter,impnws,demolish onyr repair asmemre _
O prior to its issuance,also requires the applicant for such Permit to a signed statement SPECIA1,Cl RCUI'I'/M ISC.
that he is l icensed p....nuo the IF snonas oft he Contramols License Umv(Chapter 9
60 (commencing with Seninn]IXX11 nl Uivinionlofthe Business anJ l'mfexsinnx Cale)nr 1'F.MP.MISTER(IR POLE INST. COMMERCIAL
14 Oo y that he is exempt therefrom and the husk lin the alleged exemption.Any violation of ❑Ism BLDG/ADDITION ❑DHMO.ITION
m Section 1031.5 by any applicant bit',permit xohicol the.ppiicam m a civil penalty of POWER DEVICES I' -
notmomthanFivehundreddollarsWILL), ❑IMPROV ❑FOOD 5I'.l2VIGE
IMPROVEMENT -
❑ Lwnwneek.the and Inductior myemplendes wiN wages Bred for
their sole cmmpensolion, SWIMMING POOL ELECTRIC
$$$W will drthe wons Cash, he Contractors
Lacer.1-awdoes otaale pply['I of wr,'If ❑OTHIiR
W�'� anJ Professions Code:'fhe Commctnr's License Isw tinea not apply m un awndr of OU'lLE1:N-SWITCHES-FIXTURES -
prothi who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements am not intended m offered for NEW RISEDIRIT b I.EL SQ Fr.
sale.If.however.the building or impmvemem is sold within one yemofcompletion.the SQ.FT.FLOOR AREA S/SQ.Fr.
mer builder will have the human of proving that he did not build or improve for put- s
Prom of sale.). Pj
Fl 1,us owner of the property,am exclusively contracting with licensed contractors to IOTA[.:
ennstmct the projcid sec.7IW4,Inosines and Professions Cale:)'Bad Contramor's U- �
cruse Law does not apply loam owncrofpropefy whobofds or improves thereon,and QTY. PLUMBING PERM FEE SEP t(Gg
who contracts for such ymjems wlnt a aemractar(s)licensed pars,,to the Cunumo"
License Law. PERMIT'ISSUANC
I am exempt under Sea. ,B&P C lin thixrcasnn arch
ALTITR-TRAIN tit VI!NT-WATER(GAT VALUATION
Owner Dote
WORKER'SCOMpfNrjurym DECLARATION BACK PLOW PROTECT.DEVICE
affi
I hereby affirm order penalty of perjury one of the following declarations:
Indian,
as ono will maintains Cion 3700 ofCmkmt Emtoself Code,for the
Wader's Compem DRAINS-MOOR,ROORAREiA,COND. S'rORIPS TYI'Ii CONSTRUCTION
workas provided for by Sectional. of the Labor Cale,for the pdRnnnance of the
work for which this permit is issued 1IX'I'l1RIi5-I'lik TRAP
❑ 1 have and will ode,fin Workers Compensation w rk bar which
h his required by Section
371111 u1'Ihe Lahar Code,for the perfnnnxncc niche work farwhiclnbi.v permit is issued GAS-HA.SYSTI!M-I INC.40UTLITTS (ICCs GROUP AI'N
M kre C pensa�nInsyranee natter and Policy00 -
rnco-\s-=Z1 IaIVA Policy No.:FYW-rcO GAS-IiA.SYS'1EM-OVER4WA)
CERTI FICATE OP BXI?MIMON FROM WOR KHRS' GIIITASIIINDUSTRL WASTE INTEHCEI'IY)R
GDMPHN$AT'IONINSURANCE BUILDING DIVISION Ff!6N
This accummediol hecompleted ifthe permit is Barone hundred dollars($1000 GREASETRAI'
nr less.) PIANCItITCK FEE
I certify,that in the perfonmmue afthe work herwhich this permit is issued.I shall SEWER-SANITARY-STORM I!A.200 IT
not employ any person in any manner sou to become subject n the Workers'Compen- I ENERGY FEM
0Z xatine Law.of California.Dale WATER HEALER WNENT/ELECIR GRADING FIAT
Applicant
NOTICE*1'0 APPLICANT.If,after making this Certificate of Eawnption,you should WATER SYSTHMG`REATING
F" �N5^ become subject to the Workers Compensation provisions of the Labor Cale,you most
SOILS E'l'i'
F-i Bmhwlth comply with such prnvkin is or his permit shall he deemed revoked. WATER SERVICE
Q
� rZCONSTRUCTION LENOINCAGENCY NEW RESIDENTIAL PLMB. SQ.PR I'ND Dole Receipt#
L)Q week
which
thatthereirao!(See construction lendingagency for the performance of
� the work for which Nis#azoic is issuW(See.3119],Co.iv.CJ
Ubender's Name TOl'A L:
Lcndels Address IOTAI. BUILDING FEE
y I deftly tial 1 have read this application and state that the above information iszw f'7
rF.
Vi correct.l agree to comply with all city and countyordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
UZ� building construction,and hereby authorize representatives of this city to enter upon the SEISMIC PEf: sitaia,
ah te-mentioned property for inspection purposes. FERMI'IISSUANCE.
(We)agree to soml
us,Indemnl fy and keep haress the City of Cupar ia,against I!LHCI'RIC 1131!
Ilahilitles,judgments,cos#and expenses which may i n any way accrue against said City ALI'Hk OR ADD'10 MF.CH, -
in eonsequemce of the gadding mf this permit PhI1M If TNG PIiU
APPLICANT Dii
ERSTAN ND WHA,COMPLY WITH AIA,NON-POINT AIR DANDLING UND(TO 10,"CFM) " It
SDURCE RF MATIONS. MECHANICALEEP,
AIR HANDLING UNIT(OVER 1000XICPM) CONSTRUCT ION TAX
Signature of Applican nntr.no Dam EXHAUST 11001)IW/DUCD HOUSING MITIGATION FEE
AZARDOUS MATERI DISCLOSURE
Will thea cetorfuture Isaldingec panismreorhandlehazardousmatedat HEATINGUNITTO I01,000 BTU)
as defined by the Cuismurm Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25592(.)? HEATING UNI"f(OVER 100,000 It-[ B
E]Y. „p No PATO -
VF,NfR,ATIONCAN(SINGLERES ID) Date Receipt is
Will the applicant or future building occupant use equipment or devices which
emit hazardous air conmmlwnts as delimed by the Bay Arca Air Quality Management ROUAR-COMP(7HPOR I(X.01 BTU) TOI'AI.
District? BOILER-COMP(OVER 100,010 B'HJ)
❑Yes No
I have mad Ne hazmJous Imamrfals requirements under Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCE DATE
famin Health&Safety Cole,Sections 23505,25533 and 23534.1 understand that Hine NEW RPSIDENTIAL MECH. SQ.PI'.
building does not currently have a towel,that it is my responsibility to notify the accupenl
of the).,Imreberm which must be mot prior to issuance of a Certificate of Occupancy. �\T��/.�1j�
Owner or amhndzed agent Dole TOTAL ISSUED BL^ 'a V � � .
OFFICE