29681 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CU IERTINO BUILDING-ELECTRICAL - PERMIT NO,. 29681
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HIJILDINC DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL ,'/9 6 81
BUILDING I'ROdECI'IDEN'11FICATION ' L J V 8 1
UR DING ADDRESS: SANI'I'AkY No. APPLICATION SUBMIT TAI.DATE
SZ . ICC /✓ N C C/tJ/OG�GJ//tLll ' 'L '�I t"�
'S MEi Z�PHONE
(: _ • NTItACfUR'S NAME: LIC NO:
007� NIC CONTROL.M
.RC ITECIENGINEER:c7f� LIC NCCl////SS I ADDRESS:
CONTACT. PHONE?: BUILDING PERMITINFO
Q Consultant Fees Paid by Applicant(initial) BLDG- EJLEEECCfTT PLUMB MIMESECHH
a LICENSED CONTRACTOR S DECLARATION • <
I h by ff th I I m 1' ed u e p ns of Ch pI 91 mmenc in, QTY ELECTRIC PERMIT 17EE JOB DESCRIPTION'
F,CalZ with Seco 7000) fDi Division Busi dPmf:sion Cud d fie urs '
C ofullfoneaudeff.u.. it - y e PERMIT ISSUANCE RESIDENTIAL:
=UzU License Class Lic.# ❑SFDWL /_7^��KtaI ZTCHEN REMODEL
�6S Oum Comracmr APPLIANCES-RESIDENTIAL ❑ADDITION 0Pl.UMBING R&PIPE
ARCHI'TECT;S DECLARATION PANELS - -- ❑MULTI-UNIT ❑STRUCTURAL s
Z p Z 1 understand my plans shall be used as public resorts
O Z MODIFICATION
fittic
C UP TO 20U AMPS ❑INTEItItJR ❑CHIMNEY REPAIR
Laensed Pnslessmnol s" 201-HaflOAMP5� OK'NER- - IMPROVEMENT
PUILDER DECLARATIONd 1 hreby (Sec re E ant exemyl ram a r Cssion, dx License ty o for theaOVER 1000AMPS ❑HATH REMODCVREPAIR DEMOLITION
yU followwhichrv,mmng om(Seetion 70..hurt,itherasaad Professions Co de:Any city mouname, SIGNS ELECTRICAL ❑OTHER
O F which inquires n Permit al-to ire, h L aper,impmvq demolish, fi repair ed stmemre _
N Ja anon[ t Ln y p pale If 1 p t 6 d m9 SPCCIg1,CIHCIIIT/MISC
} mm he licensedp- amu thep z fm Contractor's Lcen la (Chapter9
00 (ecrommonving with Sesta 7000)of Division J ofth Business and Pro fe Cdc)cr TEMP MCTEROR POLE INST. '
d cys thnt h rapt the f d theemis 1 th (leg d exemption,A y t 1 fon of - - '
W^u• Section 7031.5 by on applicant fora NEW BLDG/ADDI'T'ION` ❑DEMOLITION
1y_N any pennn subjects the applicant of POWER DEVICES
F p,.not more than five hundrul dollars(g51H1). . . ; TENANT ❑FOOD SERVICE
2dp0Las ownerofthe prepeny,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT', it
F will do the work,and the stmcture is not intended ornRered for sale(See 7044,Business ❑OTHER s
aand Note...i ns Code:The Contractor's License I.aw docs not Igtaly m Ira owner of OUTLETS 7SWITCIIES-FIXTURES
progeny who builds nr improves(hereon,and who does such work himself or through his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sou.If.however,the bidding orlmprovens,is sold within one year ofcomplelion,the S0.FC Iy,OO1t AREA SISQ.Irl'.
owrcr-buildkr will have the burden.fproving that he did not build or improve forpur-
pouarsule.)..
❑1,as owner of the PmNdy,am exclusively contracting with licensedcontmemn to TOTAL:
embus,the pzojen(Sec.7144,Business and Professions Code0'[be Contractors Li- FEB
Li-
versa m Q s.Low does not apply an owner orproperty who builds or improves thereon,and TV PLUMBING PERMIT 'FEE 1900 -
who contracts for such projects with o contractors)licensed pursuant mthe Contractors 96
(�
License Law. PERMIT ISSUANCE . "'I Y Ur
❑ arae (under Sec. - It&PC linos ma. n VUI"Cry1EIV '
Ofaicil
Date ALTER-DRAW&VENT-WATER(EA) ,VALUATION
OIHSL'HIS COMPENSATE DECLARATION' BACK FLOW PROTECT DEVICE -
ccbyaffrmundcrpenahyofperju a oflhe following declaralionx:
CFO] ve mW will molnwinu Cenifcaie nl'Cmnxnn[o semlmure Fr Worker's Cempnn- DRNNS-FLOOR,ROOF,AREA,COND.
cation,as provided for by Section 370D of the lsbr Cale,for me performance of me '" STORIES TVI'Ii CONSTRUCT ION
work for whichmis permit is issued. - FIXTURES-PER TRAP;
-
❑ I have end will mainldln Workers Co mPviol(ion Instmence,av required by Section
3700ofthc labor Gale.furthe perfotmuceofthew'ork forwhichmis Permit is issued. GAS-ISA.SYSTEM"I INCA OUTLETS OCC.GROUP AI'N
My Worker's Compensation Insurance carrier and Policy number are:
Carnet: I -Policy N..: GAS-HA.SYSTEM-OVEH4EA)
"
CERTIFICATE OF EXEMPTION FROM WORKERS' ...
COMP17NSATION INSURANCES - GREASEIINDUSTRI.WASTE INI'ERCEPTOk
(This section need nm bec.mpleteJ if mepcnnil is for one hundrM Aollass 15100) - BUILDING DIVISION PEES
Or less) m GREASP.TRAP PLANCHECK FEE
I ttnify that in the jx;rforrance ofthe'work for which this permit;,;.weed,In hall
SEWER-SANITARY-ST(1RM EA. F1:
not employ any person in any manner so as m timma subject t.the Workers'Cnmjmen' ENERGY FEE
Z, mina Laws of California.Date -
O - WATER HEATER W/VENT/BLECTk GRADING FEE
Z 0' Applicant -
h NOTICE TOAPPLICANT.the Work If,after Corimaking this Cisions or of Exemption,you should WATER SYS'IEMOREATIN(I
a 5 Ixnmm subjectm the Worker's ;sons or this Permit
has or the Lned Code,you oats[ SOILS FCC _
W
forthwith comply with sucM1 provisions or this pemmil shall MDeemed revoked.' WATER SERVICE
7 'z CONSTR IJC'I ION LENDING AGENCY °" NEW RESIDENTIAL.PLMIL SQ.FT. PAID
U O (hereby affirm thathem is a construction lending agency for performance of L t Receip '
the work for which this permit is i xnned lSec.31a)7,Ci¢C.)' '
U Lender's Name - TOTAL:
W Lenders Address 'TOTAL:
gy 1 certify mm I have read thin uppl kation and stale that the above i d nmWoo is BIIILDINC FEB
rn correct.i at.In comply with all city and county ordinances and state laws ielatinglo QTY, MECHANICAL PERMIT PEE -
" UZ building construction,and hereby authorize representatives ofthkeitytn enmroput me. SEISMIC FEE `
above-mentioned property for inspection purao,es, .'
(We)agree,to save,indemnify and keep harmless the City of Capetian.ti,mmt i'F.RMI'1'ISSUANCE ' ELECTRIC 72
liabdilies,judgments.coax.ad expenses whichrotiy many wayaccmeaguimtsxid City ALTER OR ADU TO MECH„
in etmseyuenre of lbs graining.;this penniL' - PLUMBINGFL','
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE.REGULATIONS.( AIR HANDLING UNIT(TO 1(1.11(10 CPM) MECHANICAL
' ,
AIR HANDLING"UNIT OVER 10,(XN)CFM) CONSTRUCTIONTA
Slgnmureol'Applicant/Cninmcmr Date 0. HX6USTH0ODIW/EDUCT) - DOUSING MITIGATION 'EE
HAZARDOUS MATERIALS DISCLOSURE;
Will the applicant(ir future building occupant store or handle hazardous material HEAHNGUNIT(TO HXBO )BTU) r
as defined by the Capenino MunicipalCode,Chapter 9.12,'and'he Health and Safety
Grade.Section 25532(x)7 - s HEATING UNIT(OVER 100,003 BTU)
❑Poe E]No
VENTILATION FAN(SINGLE RESID) PAID
Lo
ll the applicant or future building - Dam Recoil
Pp gcecupam use equipment.r devices which ROIhCR-COMP(Jfll'OR ITAI,OW RTU
oux air comm�tirouR u.s defined by the Bay Area Air Quality Mormgen em ) 'rornl.cs, ❑Nn - BOILER-COME(OVER 100.0000TU)
ve read the hazardous materials requirtmenls ander Chupler 6.93 of the Cali" AIR CONDITIONERISSUANCE DATE
hh&Sarmy Gra Secliom 255115,2551]and 25534.1 understand ihm if IheNtlWIiESIDIiNIIAI.MECIi. 9Q.FT.s not cmrcntly haves mount.Ilia[it ismy resrymsibilaytoroily theacupanl irements which must be mel anon,issuanceofa Cenifcate ofOccupancy.othonzcd a gem Date
TOTAL: ISSUED BY:
OFFICE t