S 1354 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CU PERTINO PLUMBING-ME;_'IT NKAT rh�1f NO. 1354
RUILDINGDIVIS10N APPLICATION/IaERMIT PLUMBING TET IFICA
I4UILIlINf.I'xO.II:CT WENT'IFICA'IION
BUILDING ADDRESS: / ' SANITARY NO. APPLICATION SUBMI TI'AI ATF.
L,E/^ Lei /1
OWNER'S NAME J) ID CON'fItACTOIC$NAME: L .NO.
U N/C CON'IROI.k
IIIIIIIIIIIIIfAl r,LIC NO: ADDRItS$:8 L� _ ❑
CONTACT: PHONE: L/l•�J (r BUILDING PERMIT INFO
n—� ❑ Consultant Fees Paid by Applicant(Initial) BLDft ELECT PLUMB ME❑CH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I toothy antra mel I am licenced under pawislma of chapter 9 mommonemg JOS DFSCRIPTION
WO OZ th Seaton7 )ofDbi nnJofine Business an d[' fess;nsG u license,, RESIDENTIAL:
WOO wr PERMIT'ISSUANCE
FWF nfullforce:mde t� O CSFDWL C KITCHEN REMODEL
�U(� Liccn.c Clus Co.M APPLIANCES-RESIDENTIAL. ❑AUDITION CPLUMBING RE-PII'li
F W Dare
Contractor
ARCIIITEC'I'S DECLARATION ChfGLTI-GNIT CS'TRGCPIIRAL
1..,❑m PANELS )IFICATION
z p m z I understood my plans shall be used as public recoriL
O z�-E UP TO NX)AMPS CIM'ERIOR IMNEY REPAIR
h�~W Licensed Professional 2111-10X0AMPS IMPROVEMIiNT . CS MMING POOLS
OWNER-BUILDER DECLARATION OVER Mill AMPS ❑BATH REMODEVREPAIR CDh:MOLITION
1 hereby infirm that 1 and nerrpt borrow is Como License Law for the
�°('OR a U following reason.(Section 7031.5,Business and Professions Code:Any ciry m enunty SIGNS ELECTRICAL C OTHER
1+1 4 H which requires a permit as constrain,alter,improve,demolish,Is repair any structure
Ipp'��O�nn� print its issuance,durregalrcsthe applicant far such .is file a signedsammenl SPECIAL CIRCUIT/MISC.
A�p that he is licv,,sc,ouammbut pmviximlxnl'the Conuamnh License I.aw(Chapter 9
�W (commencing with Section Tlf )of Division 3 of the Business and Professions Cdc)or TEMP.METER OR PULP I'. COMMERCIAL;
d p li that he is exempt donefmm and the basis far the alleged exemption.Any viontion of ❑NT:W BLDG/ADDITION C DEMOLITION
Wm w Section 7031.5 by any applicant fora permit subjects the applicant to a civil penalty of POWER DEVICES C'FHNANT ❑17001)SERVICE
� Qnot nmre than Eve hundred dollars(851(1. IMPROVEMENT
I,us owner of the roan.ono an to cos with wo es..thoirselemm tion, SWIMMING POO H.FCTRTC
a C p n r r n r g ,Bsa
L. .ad
mewnrk nodthe he CmdisnotintendednrmTertdforsal apply 11)in occur of COTHER
and I'nrfessinns Coda The Cnntmcmr'x License Law Anus nal apply m an owner of 011'fL13T5-S ITCHES-FI TUNES
property who builds or improves thereon,and who does such.,at himself or though
his own employees,provided that such improvements ore not intended ar"fibred for NEW RES ENTIAL ELE SQ FT.
sole,If,however.the building or improvement is told within, year of cnmplerion,the SQ.IR.I FLOOR AREA SISQ.IT.
owner.hudder will have Ilse burden of proving that he did nm build or improve for pur-
wee of ale.).
1,as owner of the progeny,an exclu,ively contracting with licensed commuters to AL:
consumer the projret(Sec.7014,Business and Professions Gde:)The Cnntreem!'s 1i
cense Lew does not apply to an owner of property who builds or improves iberes,and PLUMBING PERMIT' FEE pp
whoeum etsfasu
r chiniJe"s with a cnmmmnrlsl l isrnu
sod purseanntho GmlrainrXy
's P t
License Law. .RMIT ISSUANCE
❑ I um ninon under Sec. .11 k P C for this.reason
Owner Dae A -DRAIN&VENT-WATER IFN
WORKER'S COMPHNSA'I'[ON DECLARATION HACK 'NDIIiC'i'.DEVICE /+Iryru
I hereby affirm under penalty of perjury one of the fallowing declarations: V I
C I have and will Maintain a Certificate of Consenuo sel6insure for Worker's Compel- DRAINS-F OOk I s,AREA,COND' S'I'ORIFS 'PE CONSTRUCTION
sation,m provided for by Section JUNE of the Wtmr Code,for the per&mmance of the
work lift which this permit is issued. FIXTURES-PER A411
C I hive and will maintain Worker's Compensation Insurance,as required by Section
371(1 of rhe Lubar CnJe,lin mop ce n(the work for which this pe i is ed. GAS-fiA.SYSTCM-I INCA OUl'I. S OC-C.GROUP AI'N
My WorkrflCnt nsnion Ins 'anon.rend l'nlicY um
Cavia nlicy No: GAS-RA.SYSTEM.0VER4(7 1
CERTIFICATF?OFEXEMI NFRI ORKb:RS'
COM PENSATION INSURANCE, GREASVANDUSTRL WAST/INTERCEPTOR BUILDING DIVISION FRIE
IT section recd net he completed it the permit is for ani hundred dol tra p$10) GREASETRAP
or Ins.) PLANCHGCK PEI;
I eerlily then In the perfimnonce afthe work for which this permit is issued,)shut SEW LIR-SANITAH -S"TOR(EA.21q FI'.
me employ any person in any manner so a m become subject m the Workers'Compen- ENERGY PEE
7-s xmion laws of Cali Ramie.Date WATER I IEXrE NENT/ELFCIR
z 2 Applicant GRADING FEE
NOTICE TO APPLICANT:If,ager making this Cenificae of Exemption,you sh add WATER SYS' .MO-REATING SOILS FEE
a ; become suhjed m the WI,ker'e Contpensalion provisions of the Labor Code,you rots
W forthwith comply with such provisions or this permit shall be decmedrevoked. WATERS VICE:
Is
CONST'RUCT'ION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FL PAID
I hereby affirm that them is a conxlmninn lending agency for the pe
rfornmare of DoleeeiprX
L)- the work for which this pnmil is issued(Sec.3097,Civ.C.)
0 Limner's Nans, TOTAL:
{UIJ Lender's Address T(n'Al.:
I cci ify thm I have read this plicmion and smrc that the aMwe infnnnatioo is BUILDING A!
(Z) court l agree m comply with all ny dcounry ordinances and luno law.v relwingm QTY. MECHANICAL PERMIT FE
LJ z building construction,and hereby thou cupresenativcn of this city m enter upon'Ile
SEISMIC PI3E
ahovo-memiondl propcdy for ins "inn urryrsas. PERMIT ISSUANCE
(We)agree a,indent ify nm keep harmless the City of Cupenims against ELECTRIC FF.13
liabilities,judgnn• s andel eerie, hich any in any way uccmc:gains said Ciry AIAHRORADD'IOMIiCIi.
in conuqucnce o th gr sting of is per sh. PLUMBING FP.fi
APPLICANT U IR' 'ANDS r NO 'II.L COMPLY WITH AL1,NON-POINT AIR HANDLING UNIT LTO 10,M)CFMI
- MECHANICAL PEE
SOU T NS.
AIR HANDLING UNIT(OVER 10,0`316 CONSTRUCTI(IN TAX
St ofApplicnUC to r [371cLXf1AUS1'1100D(W/DUCT') H(IDSING MITIGATION FIiIi
HA OUS A117RIALS DISCLOSURE
Willthe applicant or'du ildings
scetuall ure ova
r handle "
c.,mtrial 1 IHAI'ING UNIT(TO 1017 BTU)
as Acrn d by the Catarina. ieind C"1e.Chapter 9.12,and the 11 dm and Safety
Cade.Section 2553200? HEATING UNI'T(OVF 100,M0 BTU)
El yes )LNo VENT]I.AITON )X IS I NOTE REST D) PAID
Dam RcceiPl#
Willthe Plaiting otter rr ints a building by the nay ArcoequipmentitQmlhe,Management
BOILER-C 1P(3HP OR 100.000 BTU)
emit hnsaMous air"mmminnms ax defined by the I3uy Area Air Quality Managentcm TOTAL:
OistricrT
C Yes �No HOILT:R 'OMI'IOVIiR I(q.010 BTU)
I
have
rmuil :vm'sn'mte' Is"'ne"anounder Chnpmrh05 a film Cab- AI NDITIONER ISSUANCE DATE
firma Heu11h&Suf Crile.Seen ns 55115,25333 and 25534.1 undersand that if the NEW RESIDENTIAL MECIL SQ.FI'.
building Jnc mtlyhnven on .than it isnryrcsprmsibiliry t000tify thceeamam
of the ich must be, is poor In issuuneeol'a nl til fenestar �/
trenre 3FI.
Owntrortmadmi.ages Din 'TOTAL: ISSUED BY:
OFFICE