S 1744 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUI'ERTINO nun.DlNc-ELEC'TRICAI. PE18�aIT NO.
BUILDING DIVISION APPLICATION/PERMIT' TING FROG aH?CRANIFIC J 1744
I4U11.1)INI:1'NO,IRC'1'IDENI'IPICATION
BUII.D1NGADUk FSS: SANITARY NO. APPLICATION SUBMITTAL DA'I
1 p
OW R'S NALo II 1'pT COMfRACfOk'S NAME: LIC NO: —��
Q LVw 74—oTkic— MNIC CONTROL#
•ARCHITE.CEIENGINEER: IJC NO: ADDRESS: ❑
CON'rACL 1� PHONE: O ,BUILDING PERMIT INFO
C/.$�-�6 til ❑ Consultant Fees Paid by Applicant(Initial) BLDG HLEC'1' PLUMB MI!CII
LICENSEDCONTRACfOR'S DECLAIRA'HON QTY - ELI?C'fRIC Pf:12Mff - FF:B
I -by E .n-I I 1 nsW u J ,nr Chad"')amt tt ung _ JOB DESCRIPTION
paZ wld5 7dup C she ea. - JP fxsn,nctalaad l'c sc IjF.SIUF.N'flAl;
WOO In PERMIT ISSUANCE!
1111 If B 1. 3� ❑SFDWL ❑KITCHEN RCMQUEL
�UF' License v Lib# APPLIANCHS-RESIDI!NTIAL ❑ADDITION ❑PLUMBINGRE.PIP3
'D Dam , Contraanr
Vn� AHCHITELTS DECLARA'f ❑MUTAI UNIT ❑STRUCTURAL
p.0 y PANELS
Z p N Z 1 undemmiJ my plans shall be used as public ret rd. MODIFICATION
OZ� UPTO2WAMP5 ❑IMERIOR ❑CHIMNEY REPAIR
I=�f" Lirmmnall Professional 201-1000AMPS IMPROVEMENT (]SWIMMING POOLS
OWNER-BUILDER UECLARA'1'ION OVER 10MAMPS ❑HATH REMODEIIREPAIR ODEMOLITION
C W Q I hereby anm em
ffirm thou 1 mo Tram the Contplanns
r's License Law for the
06 U followin Section 7031.5.Business and Professions Cole:An til t ❑OTHER
4131EI' which requires rcnss a e t to consumer alter,ire demolish,or repair Y u�stmenre SIGNS ELHCI'RICAI.
y quires r Penni prove, Pnir uny s (...L///s-/7DI,�+S
{uwpn Priormits issnuncu,also rcyuires the applicant tnrsuch permitmfilw signal statement SPECIAL CIRCUIT/MISC.
$ p. thin he is licunseJ pursuant alimpmvLstons attic Comntnm'n 1.1¢nsc l.aw lChapar9
dO ness and PricssLmsCode)or 'I EMP.METHR OR 1101,13 INS"L COMMERCIAL:
fit dx p C thin he Is ueraid therefrom and the hath lot the alleged escntptinn,Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W Smllnn 911.31.5 by any applieam for a pe,mit uhjecm the applicant u"Ill penahy of I POWER DEVICEEl
nm none than Svc hundred dollars(5500). TENANT ❑FOODSERVICE:
IMPROVEMENT
Q D 1,us owner nl'lha propcny,or my cntployrex wish wages us Oreirsnlc nungtemotion, SWIMMING POOL E!E.13C'I'RIC
y0 wJtdulhe wnrk,undthc"...lure isnot imendedorolfar,i lbrshle(8ao.7044, boinws ElOIlIFIt
d 3 lis and I'rsdessan,Code 'I Conitnnors License Law docs inn apply mall owner of OUTLETS-SWI fcUES-171X'I URE9
propcny who baud,or improves damor,and he docs xaeh work himsolf nr Enough
his own employees,provided that such improvements arc not Intended or offetcd for NEW RESIDENTIAL 1!LHC'I'R SQ ET.
sale.If,however,lire building orimprmement is sold within one year ofcmnplelim,the SQ.IT.Q.OSISQ.14.
wncoho Wer will have the burdenof paving thin he did not huild nr improve for Pur- 'flf AE
R EA
rysc of soled. aD
TOTAL:
❑ 1.as owner of Inc propenX am exclusively contracting with Iicemod complaints to �Q
nn.ruct des out (Sec..a4,Business and n,who
CoukO'Ibe Common.,
wh,On.,,onwdtxor such apply roan with
aolminous whoseilJlti improves Contractor'swho projects licensed the s%�
E]I..I esci r UreYUI
PERMIT IS A 9 L) V
❑ tum exempt under Sec. .Bhl'C for tM1i<rcason C11y
ALTER-DRAIN VP -WA'rli IA) VALUATION
Owner ❑:nc
WORude,pCall,of ATIin DECLARATION SACK PLOW PRbI'I!G )EVE'
I herdhy at 11, under penally of perjury one of the fit having Aeenvullans'.
❑ IM1:mu wulwill lmnnhnnu Cenificnueof Grmcnl In selGinemm far Wnrkcrk Camps+ DRAIN$-hLOf112,I100F, RBA.CDND' S'r(11ilES 'TYPE CONS'IR UC'I']ON
nainm tu'providdd Fa by Smarm 9]W of the Lnior Cnda,In the,doultanee at the
walk On which Ihls Ixrntit is k umd. FIX'I'Maps-ITIt I RAP
❑ I have and will maimdln Worker's Compensation Insurance,as retluired by Section
3700ofthe Lahnr Calc,forlhe penbtmarecofthe work for which chis formal is issued. CAS-11A.SYSI'EM-1 INC.40U'ILETS OCC.GROUP AI'N
My Curler:lek j, ry�s`an lnsumnrocartic Policy No,und Ek
EZIMT GAS-EA.SYS'I EM OVER 4 E!A) /•L
CER'HECATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRI,WASTE INTIiRCEPIOk
BUILDING DIVISION FEES
(Thisumuian neW nm be coorpletW if lhepermiu is Lxnnc hunJrtJ Jnllars(Ellq) GREASETRAP
orIcsz.l PLANCIII!CK LLE
Icbnifylhal in the perfennowe.fthe work for whichthis permit isisma.Isbell SEWER-SANITARY-STORM IA.200 FT
not employ any proven in any manner so us to become nn subjecthe Workers.'Camper- EN17RGY FEF.
O Z salon Laws of California.Date WATER HEATER W/VENf/f:LECTR GRADING THEZ Applicant
N01 ICF TO APPLICANT:If,after ranking This Ccnilicate of Exemption,you should WATER SYSTENM REATING
[n becumo subject m the Workers Conpensaion pmvininns of the Lahnr Code,you must SOILS PER
Wam ithann,ly with su.It Provisions or this Penni,shall he JeemednvokaL WATER SERVICE
CONS aQ
sa Z redthe kUCTIOdmilim NG ondon,AGENCY NEW RESIUI3N'I'IAL I'LMB. $Q.IT. PAID 6te Receipt#
k firwl,i,hi a,peohery issued(Sce.30Y .Cil agency lis'llm parfemmrec of
L7a the work for which Otis Penni!is issued(See 9092 Civ.Cd
L)
Lender's Add. TOTAL:
nJLecrAJdm
'n e, TOTAL:
r Q BUILDING Plata
1 unify o comply 1 have real anis application and Mam Ihm Ihm oMwe!nfm inion is
UZ builder lugrecmand hwith all erch, utyriz nmmyntativsof anA sem luesr men the QTY. MECIIANICAI.PERMIT FEE
V z building cnnalrvction,and hdmhy authorize representatives.(this city mcmcrupmuhe gIi1SMIC LLE
` above-naminned property for inspection purpnus. PERMIT ISSUANCE!
(We)agree to save,indemnify and keep hamdess the City of Cupcnlrn against I ELECTRIC FEE
liabiliuiccjudgnmms costs and expenses which may in my way accrue against aid City ALTER OR ADDIO MI!CI I.
in consequence of the granting of this permit. PLUMBING LLE
APPI.ICA N 'UNUERSTA NDS AND WILL COh1 LY WI'1'If ALL NON-POINT AIR HANDLING UNIT('ID 10,000 CFM)
SOURCE EGUTATIONS. MECHANICAL FEE
Z— AIR HANDLING UNI'I'I(IVI!R I(I,fXp CFM) CONSTRUCHONTAX
Signs rent Appli- Connector Da EXHAUST HOOD(W/DUCT HOUSING MITIGATION FEE
XHAZARDOUS MATERIALS DISCLOSURE
Will lhcuppll.um ntI...m building ocrimmu,nme or handle hamsnlmnsmlwriul H13A1'INC.UNIT(I O its)"put B'fLT
av defined by the GgreNno MmumipA Cade,Chapter 9,12.a film Health and Safety
Code,Sochou 25512(n)'! HEATING UNIT'(OVER E00000 It'U) p
-1 Yew ❑No PAID
V13NTILA'fIONPAN(SINN.I?RIiSED) Dual Reccipt#
.f a Will Iho uYnicunl or(rima building ocenpanl use equipment or devices which
out hvadous air co dourainun,as Jefinul by the tiny Are.Air Quality Management BOILF,R-COMP(7HP Olt 100,00OBTU) SAL 27.YQ/
Diovan!
(]Yds ❑No BOILER-COMP(OV I!N IIK)INNI Ii'rll)
AIR CONDE TIONIM
I have mW fithe cy CoarJnus materials 5.M53 dna under .I mid 6.95 l tthehin Cali- ISSUANCE DATE O
foods,doebr Safety Cada,Sections25505.2553]and25514.1undersand tautif the NEW RESIDENTIAL MI!CH. SQ.FT.
bailJing Jtcs sou carmnlly have a uenanu,Nm it is my resrymaihiliry In ramify the¢tory'nl d'}'
of them mems which mint he met prior once info Ce�`m of(kcupanry.
Ou'ne n authn' agent Date TOTAL' ISSUED BY. /"yCc'
OFFICE