S 1215 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUI'ERTINO BUILDING.-ELECTRICAL PF.�\Ltt1'NO,
q
BUILDING DIVISION APPLICATION/1aERMiT PLUMB OJENG-CTH N-FIFIC V 1215
131111.I11NG I'll(LII:C'I'IIIB:N'PIN'ICA'I'IUN
BUILDING ADDRESS: �/ SANI'T'ARY NO, API'IJCATIONSUI3M1'I'1'AI.DA['H
20 73 57 15"; �V�� �-25ie
OW •RS r PHONE: CON'I'RACTOR:SaA E. AC NO:
s/ NIC CON]RGI,a
ARCIIITF.CT/ENGINEER: LIC NO. ADDRf55: ❑
CONTACT: PHONE: BUILDING PGRMIT INPG
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELFPLUMB ME.CH
❑ V ❑ ❑
LICENSED CONTRACT'OR'S DECLARATION QTY. ELECTRIC PERMITFEE
1 hereby alum that I am licensed under pro>'iouriv of chapter 9(commencing JOE DESCRIPTION
DMZ with Section 7oNry dDivision 3 crib Businca and PrnIf 'on10 c.undmylicerwis q RESIDENTIAL,
�JOp wI PERMIT ISSUANCE .d�
n full force and c
w- � C1 MEDIAL ❑KITCHEN REMODEL
�UZU I,Icancc Cln.x Liab APPLIANCES-RESIDENTIAL ❑AUDITION [I PLUMBING NI:PII'I?
NQL D:IIC Cori
GHITACPS DE '10 V ❑MULTI-UN jr, ❑RI'RUC'TURAL
~NZ I understand my plans be used as public records PANELS MODIFICATION
ZOy„ UP TO 200 AMPS
OZ^Q ❑INTERIOR ❑ IMIP
F+��w LiccnsW Prnles.irnul 201-IIXNIAMPS IMPROVIiMCNT (]SSWIMMMINGNG IOOLYK)1.h
OWNER-BUILD17R DECLARATION OVER RMOAMPS ❑BATHREMOD-L IkEMOIATION
C W m
Q I hereby iffil doo I an
m esapt from the Commaor.Li amic Law for the v�
(iY�O ty U following reason.(Section 9031.5.Business and Professions Cole:Any city or crnmty SIGNS ELECTRICAL UI'HF.R
WaW1"' wLlub mImesa t man,ftml,idwr,iia
1 perini pro%r,Immobsh,or mcpnb any nuocmre
hn priol'Islits issuance,also requires the rpplitanl for such permit to file a signed slnlemmnl SPECIAL CI RCU I"1'7MISC.
fly Clothe is licensed pursuanno the provisions of Ne Contractors License Law(Chapoer9
W aQp (commencing with Section 7111)of Division 3 of the Business and Puldessimn Cock)or TEMP.MIST ER OR POLE I NST COMMERCIAL:
d a Ih:n he is escmpt therefrom and the bask for the alleged.xsrr ion.Any violation of ❑NEW BLD(EADDITION ❑DEMOLITION
N Satire 7031.5 by any a,l'Imrl for.pennh svhlecl4 the opplicnnt u)a civil Penally of POWER DEVICES El TENANT ❑FOOD SERVICE
nl more than five hundred dollars($5 W).
H Z Y IMPROVEMENT
< wi Lo the work,the tiropeny.nr myemntende.with Bred for sale
7044,Business
SWIMMING POOL ELECTRIC
' p=,m w111 dolhesious Code
rI he cture Contra tors J,amed o Law dos o,i,,,Iy to an,Business [I OTHER
til a^ oo Professions Cnda The oyes thcmr's License Law does no,apply over
r v owner of IAITLG"1'S-SWITCHES-IiRI'U
Y Pm ny who bull,s or improves Ih.all i Imd who don such work dlnxdf caf Ihmugh
his own however,
the provided Iri inch improvements thin nnI intended ar offered for NF.W RIiS1111iNT1AL Ii1.liCrk 'I'.
sale.11,however,the building orimpmvcmcnt is ml,within one year of completion,the SQ,17.FLOOR AREA SISQ.t4.
er-builder will have the burden of placing that he did not M1uild or improve for our-
arecofaale.,. P A
❑h.% wnrr of the prnpeny,a selueively am.uaing with licensed contractor m 1i
construct the project(Sec.704FU Business and Professions L d,I am ConuxaorI a.-
cenes,Law dims not apply to an owner of prupeny who builds or improves thereon.and QTY. PLUMBING PERMIT P i M
who comm ma
is lar such polecs with a com � or(s)licensed pursuwm FEB nlive Conductor's {l
Licer,Law. PERMIT'ISSUANCE
I am exempt under Sec. ,B&1'C mrthis reason
ALTER-DRAIN&VENT-WATER IRA) 1�tt A I
owner Dam
WOR KT:FUS COM PhNSA'1'[ON DECLARATION NACK PLOW PROTECT.DEVICE
1 herclry affirm under penally of perjury one e1'the following declarrion.v
useand will maintain a Certificate of Consent self-insum for workers Conover- DRAINS-FLOOR.EDGE,AREA.COND. S'I'(RIHS TYPE CONS'1'RIJC'I')ON
a%prrvided for by Section 391X1 of the Lehr Code,for the Performance of the
Krho which This permit k ismed. FIX'I UR17S-PER TRAP
I have amt will maimaio W..Lrra C...IIPansatii ln,lonce,as mptimt by Section
3 ofdw hBarCode.Rathe performancemou,work for whichlhis permit 1.isoa. GAS-EA.SYSTEM-[INC.40U'I1I.,TS OCC,GROUP APN
My Work C ' }esu gyro dPolicy
OM.W�
Coni y/ i/ ePolicy Na: ? GAS-EA.SYSTEM.OVER 4 IEA)
CERTIPI'AGE OE EXAM PTION FROM WORKERS'
COMPt3NSA1'ION INSURANCE GREASIJINDUS'1'NI.WASTE.INTERCEPTOR
BUILDING DIVISION I"HCS
(Thi,eclirn need nal beeompleed iflhepsom,is hatnalh ndradmIlars($IIID) GREASE TRAP
or 1<scJ PLANCHECK PF.E
I eenify that in the performance of the work for which this perms is issued,l shall SEWER-SANITARY-S'FORM EA.200 FP.
not clnviny tiny Prmnn in tiny else mbccomc nnhjccur dlu]ylakys'(y.tpfo- ENERGY PEII
O ,Z ration Laws rf 'o lost mncrs Z•h71{ WATER 111iATER WNIiNTIELECI'N
Z O npprcanl /` � GRADING PER
.N. NfTHCE'I' APPLICA T':If,Bit making i. a IRcam ofof ,carP WATER SYSTEM,"TREATING
r(~ Become subject m the Worker's Compensation ps,sions of the Labor Code,you..last SOILS FEE
Iolhwilh crnlf,with surh pmvi sloes m his planar Oug he dcclncA mvnkak WAT'HE SERVICE
G
CONSTRUCTION
utionLENDING leading
NEW RC9IDENTIAI.1'LA1B. SQ.1T. PAID
V Q I hereby affirm that isacomtmai30 len ding agency Gn the performance of Date Receipts
Thr work lin which this lwrmn Is issucJ(Sm.3097,Co.C.)
Lenders N.nm TOTAL:
U Lenders Address TOTAL:
I eenify that 1 have ma,this application and state Ihm the Move information is BUILDING BLE
� y correct.I agree to comply whit dl culann county onlirance%and state laws rehuing to QTY. MECHANICAL P17RMIT Ili
V huildingconuhoction,ahereby rmbr.isrepreseh.ntives of this ally nl emcr n poli in. SEISMIC FEE
.hove-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep hassles.the Cil,of Cupcnino against ELECTRIC Plili I
fabililiec,judgments,costs and expenses which may in any way mance agairrosaid City ALTER OR ADD TO MECH.
ousequenec of the gaming rf(his prnnlh PLUMBING PEE
A PPIACAN'I'UNDER S ANDS AND WILL COMPLY WI'I'II ALL NON ED IN I' AIR HAN DI.I NO U N I'I'('101(Laid CEM)
SOURCE REGULATIONS.
MHCHANICAI.ILB
AIR HANDLING UNI'r(OVER 10,000 CFM) CONSTRUCTION TAX
Signature ol'Ap,iearOCondacmr Dole EXHAUST HOOD(W/DUCT) HOUSING MI'I'IGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the.p1batial or forme bidding asom,unlemre or handle hstragmsnoterial HEATING UNIT TI'O IINt"t,U)
as defined by the Cuticular Municipal Code,Chapter 9.12,and the health and Safety
Cade,Section 25532(a)1 HEATING UNIT(OVER 100,000 BTU) 1
❑Vcs ]�Nn PAIDYZ
-
�,` VENTILATION FAN[SINGLE N0.SIU) ])air Receipt#
Will the applicant or future building occupant use equipment or di ices which
emit hamNous no,contaminants as defined by the Bay Area Air Quality Management BOILER-COMPQHPOR 100,001311111)
TOTAL:
District'
E]Yxs .p^f�� BOILER-COMP(OVER xfox IJ'ni)
I leave least the haaNnus mmeands requirements under Cbaptar 695 of[lie Cali- AIR CONDITIONER ISSUANCE DATE
funis Hudlh&Safety Cala,Sava...25505.25533 and 25534.1 unclvionved limit the NEW RESIDENT Al.MHCH. SQ.EL
hIbI II docs tan cunendy htrvcn Wwnl,Thal it is Illy lcspnrt ibll'uy o-n nrnily tar naupum
en&w ' tlmst a Immpri t rnf.CenllicatcrfOa
agr / Date TOTAL: ISSUED BY:
OFFICE