S 2580 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUI'ERTINO
BUILDING.ELECT R' 1'ERhf IT NO.
Buu.mNc DIVISION APPLICA'f10N/PF,RNI'1' rLumnwc-nn!cxgNTcsl. S 2580
BUILDING PROJccr IDF.N'I'IFICA'I'ION
HIJILDINGADDRESS: SAN1'I'AKYNO. APPLICATIONSUBMITTALDSFIi
I 3 pov/4" Co"AT, casy&kf+/vo CR (,Lora 1 Z- ZZ—'?
OWNERS NAME: PHONE. CONTRACIURS NAME: LIC NO:
T,4y1C- Wqr 6,ways-/88Sx/L /yL NIC �IcovrROLa
CHYPE '/HNGINEER. LIC NIT. ADDRESS: ❑ c `7
E CN[�✓ C'2 PH d l/
CONTACT: I (u PHONE n ❑ Cunsialmnl Fact;Paid by Applicant(Initial) BLDG _OI ELFC[LDING PFRPLUMp MIT f•O MECH�
M 11<e cWtoi 72 2.5 `F 2—* n rod/ F
LICENSED CONTRACIORS DECLARATION QTY ELECTRIC PERMIT FEL''
hereby affirm mm I all,licensed ruder prc,-itiaro of Cham,,9lcom.neneh, JOB DESCRIPTION
�lrZ thSmtinn IltWlof Division?nf the Business and Professions Cnle,unJ my is
RESIDENTIAL
WOp wh PERMIT ISSUANCE
F- full Rome and effect. .)WL ❑KITCHEN REMODEL.
d',1- m
QUV License Class Lica APPLIANCES-RESIDENTIAL ❑ADDITION L1 PLUMBING RE-PIPIT
�Z Dmc Cmuncu,r
<WZto� ARCHITECr'S DECLARATION PANELS ❑MULTI-UNIT [_1 STRUCTURAL
ZpHZ ,understand my plan.shall hemedaspnhlic records MODIFICATION
OZ=� uP T02INIAMPS ❑PFIERIOR ❑CHIMNHYREPAIR
W Licensed Pmlcs.aional 201-11Mq AMPS IMPROVEMENT SWIMMING POOLS
CY�� OWNHR-BUILDER DEiCLARATION OVER 11xq AMPS G BATH REh10DEIlREPAIR ❑DEMOLITION
m w a 1 hareby afama mal 1 am exempt frl,m the Contractors Licence Law Flume
W 3 U following mason.(Section 7031 5,Holiness and plate ssams Cale:Any city or county SIGNS ELECTRICAL C1 OTHER
y whi 1 1 rat l lo,ousnact,ad'e'. pooe,J nnlad 1' 'any Mornina
F �' fres t I .: aE y :Ih pPli' II 1 p nni0 6 edetate nen SP17CIA1.CIItNITIMISC.
� 'hath Icer. dpursu pursuant m provisions of the C sof t Lcn: L (Chapter9 COMMERCIAL'
ZW (commencing with Section 9000)of Division 3 of the Business and Pofessinns Craft)at TIiSIR M OPER OR MILE INST. 95
a a p C that he is exempt dutchman and the basis for the alleged exemption.Any violation of ❑NP LDG/ADDITION ❑DEMOLITION
�H
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penally of POWI2R DEVICES NAM ❑FOOD SERVICE
rat oma than f ve hundmd delhm($501).
F i VEMF;N1'
6 ❑ I.ac nwnendlhe pnhpeny,urmymnpinyee9wlnlh wages as'hcirsnlemmpensadun, SWIMMINCf POOLIILIiC'I'ItIC
p.,o will do work.and the xlcure is not intended lir enema fors:Jc(Sec.9f W.Business ❑OTIIHR
otm
W m and Professions Code The Contractors Liceno,law rocs net apply to an owner of OUTLIfTS-SWITCHES-FI%TORES
property whe builds or improves thereon,and who dares such work hinacelf or though
his own employees,provided Ibar such impowemems are not intended or offered for NEW RESIDENTIAL ELECTR SV FT
sale.Ill however,the building or Improvement is sold within oncynnofcompletim,he SQ.FT.FLOOR ARBA VSQ.E-L
own
er-builder w,Il have The hu.Jnn of proving than he did not bard of..nmr..c for par- otos
pose,,orae., k!".1.
❑I,as owner of the popeny,am exclusively connecting with licensed contractors ra p 4-
onmem the pngect(Sm.7094,Hasioess and Professions Corte:)The Conlracers Li- 213 p 3 S
cense law hes not apply to an owner of popery,who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a commons)I cemed pursuant o the Contractor's
Liccmc Law. PERMIT ISSUANCE
E] I nm axuntpl um ,Sec. ,I3&I'C fu.this lanolin 61SP
ACI -DRAIN&VENT-WATER(HA) VALUATION
Doc
WORKERSCOMPENS :CI.ARATION B ILOWI ECT.DEVICE 0 O O
er I hemby aRnm under Nruilm of perjury enc of the following declaration
I wit s:
I havcalal will maintain u Cenificate of Canocnt mself insure for Worker's Cnmpnh- DRAI - OR.,tt )P.AREA,COND. STORIES TYPE CONSTRUCTION
,in us monied fill by Scetl...3700 of the Lal Cade,fn,the perhmmonce ot'the
work for which this panni,is iawred, FIXTIJRES- '1'RAI,
❑I have and will maintain Workers Compensation Insurance,as required by Section
3700.0he Labor Cade,forth,performance of the work for which this permit is issued. GAS-ITA., 'STET INC.4 OUTLETS ocp GROUP APN
My Worker's Compensation Insurance carrier and policy number am:
Carrier: Policy No.: GAS-EA.SVSTEM-0VI!R4(EA) Vv
CERTIPICA'fIi OP B%EMPHHN FROM WORKERS' GRI:ASIVINUUS'FRI.WASTE ffGERCIII'H)R
COMPENSATION INSURANCEHUILDINO DIVISION hIJES
(Thisscenionneed lint hecompl,ted lfthepannit isfica nchundreddollae(Ma) N
GREASETRAP
lir lcsz.) C 'K FEE yD
I cenify that in the performance ofdre work for which this permit is irood.I shall SEWER-SANITARY-STORM EA.2q)PF.
not employ any person in any..an,,so as R,become subject to the Workers'Cn,open. Ii IEE
C) xanon LnwaolCalifornia.Dam WAI'HR 1117ATER WNENT/ELECTR
Q Applicant alt INC,FEET
N NICH 10 APPLICANT':IL alter making this Camf,mm of Exemption,you should WgT'I?k SYSTBM/fN11ATING
becomewb'mt to the Workers Com lion f the labor Cade,you nen Sf I S FEE
Forthwith comply Ih such a,.nhi.c ermi.staff N deemed revoked.
Q pywi pmviain pemhi WATER SERVICE
=) Z CONS I'RUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FF. Data Receipt#
hereby airrat,hut Iher,is n,.nsVnmil,n leading agency Ga the pe.Rmnhnnee ill'
W in,work to,which his penal is keed(See 3DA.Civ.C.)
Lenders Name teF
L) Lenders Address 'ITH'AL:
I cenify that 1 have rand Nis application and wale that the above information is HUILUIN
.H. Rap correct.l agreem comply with all city and coumy ordimneas and state laws return,to QTY. MECHANICAL PERMIT FEE t]I1
L) Z hanicngconsuaetirn.and hereby authorize repmsanciive,c of,Iis city menterapon rhe SE?ISMIC ^*/
ah-,ace honed formally for inspection pugmsus. FERMI'I'ISSUANCE?
(We)agree n,save,indemnify and keep harmless the City of Cupenino against ELLE t P
Iimalaies,juignmms.costs and eapenas which may in any way secure against said City ALI'17R OR ADD TO MFCTLPLUM4UjaFE:
2�b
in couseyrcnce of the granting of his .it.
APPLICANT UNDERSTANDS AND W IL.COMPLY WITH -POINT AIR HANDLING UNIT(TO 10,000 CFM) MHC ICA REE
SUURCI!RIIGD TIONS.
AIR HANDLING UNI'I'(OVER 10,000 CFM) CONSTRU ON'1'AX
Sig arc of ApplicanVC wnor Unte E%IIAIIST HOOD(WIDUCF) I10lJSINGh TIGATION PF.E Q
HAZARDOUS MA'. 11 S DISCLOSURE
Will the applicant lir future hull ag cupemseemm.dkhv.Mo.,mmcriat HEA'ONG UNIT(TO 100.000 BTU)
as defined by,he Cupeninu Munici e,Chapter 9.12,and the Health and Safety
Code,Samar 25592(a)'f HEA'1'INC,UNIT(OVER IBMXX)BTW
❑Yes Fl No VEN'I'ILA'FION PAN(SINGLE RGSII3) PAID
Date Receipts
Will the applicant o,Ruts a building by the B use i Air u or devices which
.mit haerJous air contaminants as de0ned by the Bay Area Air Quality Management BOILIiR-COMP(3HP OR I00.010 tlTW TOTAL.
District? BOILER-COME(OVER W,000BTU)
❑Yes C]No
I have marl the under Chapter 6.95 f,ha Cali- AIR CUNDITIONBR 4,4-i2enC& AfomiaHealth&Safety Cak.Sections 25505,25533 and 25534.1 undenland that if the NEW RESIDENTIAL MECH. SQ.W.
building docs not currently have mount,that it is my responsibility uh rowdy the occupant
N lie rtyu"iryln rcwM1'ch muslbon t iasu.aam of a Certificate of Occupancy
OwnernrnulhorizeA agcnn Dame TOTAL] ISSUED BY: V•
OFFICE