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PERh11I' NO.
CITY OF CUPF.RTINO
BUILDING - ELECI'RICkI.
PLUMIUNG-MECIIANICAL
O 070
BUILDING DIVISION APPLICATION/PERMIT
BUII.UING I'ROJRCT IDENTIFICATION
kJ / O
$ANI1'ARY NO.
AI'I'hICATION SUNMII'IAh DATE
BUILDING ADDRESS:
S
95
/
C
2DDD k)r �'
OWNERNA IT: 1'NONE C MHACI'
H' NAhJE LI N
'(
NIC
CONI'ROIA
❑
ARCHITECT'IENGINL'ER: LIC NO: A DJtI!SS
[/.1n
UUILI7INC
PIiRMI'f INFO
CONTACT: PHONE:
❑
Consultant Fees Paid by Applicant (Initial)
IfLlDG IlElC3 I'IAMH MECII
��! � �
El
LICENSEDCONTRA OR'SoECLARATION QTY
ELECTRIC PERMIT
FEE
JOB DESCRIPPION
1 bca,by afGmt Thal 1 am liven. under previsions of Chapter 9 (commmacing
RESIDENTIAL
wiN Section ilXMp lot nl'Ihc Busincssnnd Pndcssio e, Gale, and my license is
1'ERMI'1' ISSSUANC17
❑ SFDWL ❑ KIJCII17N REMODEL.
a full force and d&clC n /1Ll
1. G1/ Lic.N
❑ADDITION ❑PLUMBING R&1'11'11
Livery Class
Dale / �Comracmr
APPLIANCES -RESIDENTIAL
❑MUhTI-UNIT ❑STRUCfURA
ARCHITECTS DECLARATION
PANEIS
h10DIFlCATION
1 undersmnd my plans shall be used as public a,coNs
UP TO 2W AMPS
❑IM'I:RIOR [I CHIMNEY REPAIR
IMPROVEMENT (] SWIMMING POOLS
Licensed Prnfelliunal 201.1(XX)AMPS
OWNER.BHILDER DECLARATIONOVERIoW
AMPS
❑BATH REMODEURI?PAIR ❑DEMOLITION
hereby oRmn that I am exempt baro the Cnnauctor's License Law fm the
(] (Yf111iR
following rcnma(Section onict, e oAny city neounty
SIGNS ELECTRICAL
-and
moll h.orrepairany vtmcmre
which 9 Permit tosu consumer. ifte improve. demolish.
prior to its.van ahvi req % the applicantf such permit file a signedaatemrnl
SPECIAL CIRCUIT/MISC.
('OMMFRCIAL
bar he licensed prostt the provisions ofthContructons License Law (Chapter 9
"ourrarearrin, with Section 7WO) ofDivision I offific Business and Professions Code) or
TEMP. METER OR POLE INST
�NI?W BhDNADDITION ❑DEMOLITION
That he is excmpl Iharefmm and the basis ler the ullcgcd cscmptmn. Any violation of
lir suhjats the applicummucivil pcutlry of
POWER DEVICES
❑TENANT ❑ FOOD SERVICE
Section 70315 by any applicant a peoail
IMPROVEMENT
not moa, than five hundred dollars 155110).
❑1. as owner of the property, or my employees with fluar-li, compensation,
SWIMMING Food. ELECTRIC
❑OT111iR
will do the work. and the suuaura is not intended oroRemd for sale(SeeIINJ, Business
OIIILETS-SWITCIII!S-FIXTURES
and Professions Case: The Contractors License Law does not apply 10 an owner of
property who builds or improve' thereon, and who docs such work himself,,, through
NI7W RESIDENTIAL Ii1.EC1'H
l IT. l LOOR ARBA
S/SQ FT.
employees. provided that .such improvements am not intended or offered for
his own empro
vola lL hawwca the huilding or iinprovcmvInk,oldwithinoreycarote rplctin r, he
��/ J p..
proving thin he did not build or imrofor r prv-
ler-builder will have the burdmt ulro
,Y
pose of vale.).
'TOTAL:'1110
u
7Y
ri 1, as owner of the Paulen, am exclusively comractmg with licensed lettermanLi- to
Ur LVs-G
con moct the project (Sec. 70tL Business and Professions Code:) The Contractors
PLUMBING PERMIT
FEE
7 s bi J
ecase Law does not apply to an owner of propcny who builds or improves thereon, and QTY.
who cormi for such projccu will, u centmaorts) licensed Pursaanua the Comencmr'S
Licence Lax'.
PERMIT' ISSUANCE
I me exempt under, See .B& P C for this rwsron
VA L. A'1'ION
ALTER - DRAIN & VENT- WATER (HA)
Owner Date,
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT. DEVICE
I I berchy affirm under penalty of pepury one of the fallowing crelaralions:
tovif-insure for Worker'. Compen-
DRAINS- FLOOR, ROOF AREA. COND.
STORIES
'TYPE CONS'l'RUCTION
I have and will maintain oCvrbEvmcof Consent
sabots. .% provided for by Section 390(lof the Labor Code. for the perfoonance of the
k for which this permit is i .... d.
pIXrI*GR1iS-PFR
I have and will mon,an Wn ker' Compensation Insurance, as reyu red by Sectinn
E
GAS - EA. SYSTEM IINC. q OUTLEAS
OCC.GROUP
AI'N
J of the LaWr Code. for the performance afthe work for which this pcmti
My WerkeexC n' nvurancc carrier and Policy up y�l(i ac: j/
GAS-BA.SYSTEM.OVERS(EA)
Cartier: Policy No.: 7
CERTIFICATE OF 17XEMMON FROM WORKERS'
GREASOINDUSTRI. WASTE INTERCEVI'OR
DIVISION FEES
INSURANCE
COMPENSATION INSURANC
PLANCIIf:CK ITIi
0 hivwatina need not be ri i,,I,lcd if the peroul is for one hundred dollars is 11X11 GR ASI: TRAP
or Ic".l
that he to perthe it issued.
Loy manner of
SEWER -SANITARY -STORM 1A.2(X1 Flt
FNERGYItiE
or subjectch
as Wrkofs'
not employ any pawn in any manner an as m became subject to the Workers' Compen-
any wevan in Tiny
GRADWGI'EE
anon Luxs of California. Date WATIiR HEATER W/VIiNTIELECTR
D Applicant
APPLICAM': If, after making day Cerhadcme of Exemption, you should
WATER SYS'rEM?REATING
SOILS FEE
tiNOTICE'TO
become xuh'Iccl m the Worker. Comtcmminn pnrvlsiuns of the kTdWr Code, you must
> forthwith comply with rush pbaski is or this permit shall be deemed revoked. WATER SERVICE
n
CONSTRUCTION LENDING AGENCY
NEW RESIDENTIAL PLMB. SQ. FT
PAID
pate HneiptM
Z
I hereby others that hen is a conswetion lending agency for the performance of
TOTAL:
the work for which this .it is issued (Sec. 3097. Ci, C.)
Lenders Name
Lender's Add...
TOTAL:
BUILDING FEE
SJ
y I eerily that I have read This application and stale that the aMrve ialinnmtion is
MECHANICAL PERMIT
IBE
A caret. I agreem comply with .11 cit and com,ordimocc, and state laws relating a. QTY.
SI?ISMIC IIIT
Z building comuuction. and hereby amhnme mprcsenlativcvoflhis city amnmr upon the
abovrmentioncd property for inspection purposes.
PERMIT ISSUANCE
ELECTRIC FEE
(We) agree 10 save. indemnify and keep hareadc" the City of Catalina against
liabilities,judgments, costs and expenses which may in any way accrue, against said Cit
ALTER OR ADD TO M CCH.
PLUMBING ME
in nsalucnce of the planting of this permit.
APPLICANT' UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
AIR HANDLING UNI '1'('TO 10,U)OCFM)
MECHANICAL :E
CONSTHU ON TAX
SOURCE REGULATIONS.
AIR HANDLING UNIT (OVER I0.I00 CFM)
HOUSING LITIGATION FEE
Stimulate of Applicant/Conefoo, Dare
EXHAUST HOOD(WIDUCT)
HAYARDOUS MATERIALS DISCLOSURE
huildingocrament stomorhandle hmoolnuv material HEATING UNIT (10 100.010 BTU)
Will the applicant or furore
as defioal by the Cupertino Municipal Crile, Chapter 9.12, and the Headm and Safety
IIHATING UNIT ((OVER EX)OXI BTL)
Code. Scar 25532(a)1
PAID
0Yn [:1 No
VENTILATION FAN (SINGLE RESID)
Uma Receipt M
WII the applicant or forum building occupant use equipment or devices which
MOILER - COME (3HP OR 100.000 BTU)
mil hazardous air mx1aminams m JcfinN by the Huy Area Ar Quality Management
'e
T(r19L
Dlalri D BOILER - COMP (OVER 100,000 13
Vcs ❑ No
ISSHANCE DATE,
AIR CONDITIONER
1 have rod the nx nwmriuH under Chapter b of the
5.1553 a m fi ch,
fomia Hullh h Safely Code, Sections 25505.8537 unJ SSN.1 unJcmm�d the if the
Cedit,
NEW RISIDIiM'IAh MECH. SQ. FT.
Wilding does not currently have. tenant. don it is my rcsrymsibiliy to nrxif the oce nt
of em u' nls ich st he t cnf Ccnificaw of
1 ,enc
TOTAL:
ISSUED BY:
Owner or nn coned agent me
ut-rll,t