S 1867 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUI'ERTINO BUH,DINC.-ELEcrRICAL PF: lir ND
BUILDING DIVISION AI'PI,ICATION/PERl111T PLUMBING MECHANICAI, 1867
ILII I THING 1'ROJ ECI [DEN 1*1 F'ICS[[OM1'
SAN]1'ARV NO, AI'I'LICAI'I,IN SUBMII]AL UATC
BUILDING ADUNISS'.
i 7-9
OWNER'S N'AML': PHONE CQNIRAC10 '4ME: ` 1 N/C CO,NIROLa
R HIT:COHNG NE R. 1.C NOj� ADORES.' ,•VI ❑
IstLC ti
CONTACT: PHONE: ❑UILUING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) BLDG ELECE ol PLUMB MUCH
❑ ❑ ❑
LICENSED CUNT RACrOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB
1 hereby:norm thatI an licensed under pr.timons of chant,9 a,,,...le tg JOB DESCRII'1'ION
W aO lith Seainn]IHllllof Uivisinn Jul the lhe'inusund Pnd.'sinns C dg. Jury licmue lxFTF
O RESIDENTIAL;
7 ac,� !QTY. PL
MI'I'ISSUAN
FW2 full hnuwandd y ❑SPUWh ❑KI'fCHCN R1iMOUlCI.
aUU L:ccmcLlus hic'N !� LIANCES- ENTIAL ❑ADDITION ❑PLUMBING RE IIIIIH
gzw Dec / Con`s ❑MULTI-UNIT' CSTRUCCURAI,
Nab ARCIIIF17M UECLARMION
IBSMWIFICA"I'1(1N
ZO FO N Z 1 um emm�d my plans shall be used an public records O 200 AMPS
❑INTERIOR El CHIMNEY REPAIR
IMil LirenscJ l'rntc..ionul IMN)AMPSIMPROVEMENT C]SWIMMINGPOOIS
OWNICR-BUILUHR DECLAI1AI ION It I0m)AMPL1ITO I RFM(1UIilAREPAIR 0UFMOLITION
C a 1 Lercby affirm that I nm exanPl from,he Conma'mr'x hicmuc Law In,,he
K3 d U follnwing reason(Suction 7031.5.Busincss and Professions C,de:Any city or countyNS ELECTRICl OI1113R
ON
which 4 Permit Lconstruct. Iter p t list P y.t churn
F'NN J priorh , a H " theapplicantf hprm ,h fl l ed',cementCIALCIRCU .
S >'_- than I 1p w u th p n. Oh c n, , r License L (Cha er4 ,A p COMMENCIAL��Q2 fttnn g ,ISc'I ]00111 fDosu 1 ❑hellu�tcw dP fesnorecrde)orP.METER OTI ' $ V (l e C hat he is exempt Ihcrdiom u d the mania t'ur the alleged exemption.Any siltation UI ❑Nh:W HLUO/ADDITION ❑U13M01.1'CION
Seainn]1131.5 pry any vPPEcunl for a permit ounjuts hhuoppliutm m n evil lwmuhy arER DIiVIC1C'I'ENAN'P C FOOD SERVICE
F.
Fah more than fve hundred dollars(85(x), MPNOVIiMIiNT
(]Ianw'ncndlhe pmpeny.nr mycnrployce'wi,n wages us,ncir mlecmnpcnsalinn, Ih1.MING VO .IiCrRICwill dn,he work,and,heammure isurn intendedormfieted forrole(Sec.]Uta.Boeinesx ❑OTHIiR
rLITS-SWIS-19 XTURF_Sand Pm(e„ions Qde:The Colnraaors License o do s sac nm apply m if owner ofpigmy who builds ori ,done h,hereon,one woo dim'inch work riled o ror,hmuen
his own mupluyeex,prvided Inn each impnrvcnants are nnI In,cnecJ or nlTumrl Inn R13SIDENIELIiC!R SQ IT.satt.11;1 .mcI ilJmgn nal rnl—.1d wi,ninonh YaaufcI on.lion,theSQ.I'C.ELfNIR AREA ESp.I'I!c,bmindcr will have Inc holden of lmrvin,End hedu n,),build of improve for In'-
powoL,aIc.yA 0❑1,as owner of the properly,inn exclusively contracting with licensed commoners moneonct the project(Sec.]BLT.Business and Pruesxion,Csde:)The Culnracmr,Li
.w Law dues not apply to an owner of progeny who)builds or improves thereon,and PLI NGPF,RM111T FEE:ho enn,mets tareach pmjem,witha cmtmctr(s)licmiscd P,muam ho the CmnmemrkLiccnsc Law. M(I'ISSUAIu:ncxempnuWcrSec .B&PCfnr,hislvm.on ER-URAINENT'-WATER(EA) VALUAI ION
Owner DaeWORKERS COMPENSATION DECLARATION CK FLOW PRL DEVICE
1 hereby affimt under penally of perjury one of,he.following Jeclom,iens
7 [have and will maintain aCenilicamnfC.nsenl msclf.iii-neW Wnrker'n Compel- DRAINS-FLOOR,ROOF,AREA,COND. STORIES 'TYPE CONSTRUCUOs
'Tilton,as pmvidnl for by Section J,(NI It he Lab...Cndc,for the performance of Inc
work fofwhim This perntili,issued, IHX'1VRE -PER"liltAI'
1 have and will mnin,ai.Wnrkc,,Compemminn Insurance,as required by Scclinn
3100 of,he Lahm Curie fonhe peri)n,tanceof,he work fnr which this pemtih is issued. GAS-EA.SYSTEM-I INC.4 OU'1'L1.11 OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number me: GAS-EA.SYSTEM.OVER a(EA)
Cartier: Policy Na.:
CI7R"FIFICATE(IPEXEMPrION FROM WORKERS' GREASEJINDUSTRL WAS 117 INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION,EFS
(Th'wwClinn need.,),becnnrplmml ittho,brandis raronchunJresldudas(S100) GREASE'IRAI'
1'hANCIIr:CK FEE
ornc,'c)
I comity that in hhelrtdornmoccef,he work forwhichtninpemm inissued.l shall SEWER-SANIIARY-STORM EA.200 14. ENERGY I11,
nn,employ any sawmill any mann ,aJ cess yipbjeO m the Wbfkeri ....pen-
.Z when Laws n pIr(f,min.Ume - WATER HEATER W/VI3Nr/ELECTR GRADING I'lili
zO APPlicunt 72 re✓ )sN/
r.y Nf-ricr.IO APPI.ICn T:If.oiler making this Ccnilic:.c of Excmpuon.Y,a'mant NAT13R SYSTEMOREA'1'INC, SOILS FI313
F bcun..r subicel m the Worker',Cull4ren,'e.un to ski ums.I'Inc Lubar Cole,yet most
Ri r+ Emhwoll cmnply with wch pmvlsions or this permit sham be donned revoled. WAFER SERVICE
U
CONSTRUCTION LENDING AGENCY It RESIDENTIAL('LMB. SU EL 4AID
Z)Z rn Hcccip p
U 0 Ihercny affirm tnauhem iso nmwmnion lending agency for the phHormantt of
(•-' ,he work fof which This pcm,il is isnnee Sore.3091 Civ.C.) Q TOTAL:
O U Lundin',Nauru T( ' 1.:
U [,endo''AJdrexn Iruil',That I have read this aPplicminn void sem Iha the above infnrn:miun is �sN correct.l agree w comply will)all city and county ordiwmes.nd"ate law.naming m QTY. MECHANICAI4PERM TQ. J FIiE U Z building cmtslmchon.and hereby a IhI represnnatives of ods city to corer upon the �3'vM1cmentioned pmpeny far inspection purpnscs. PERMIT ISSUANCE '(We)agrce,o.save,indemnify and keep harmless the City of Cupcnina againstliabilitics,judgmelns.cos¢and cxpcmcs which may in any way went again,said City ALTER OR ADD TO MEC U•J E
no cnsequcnce at the 6ormargof tis permit.APPLICANT'UNDERSTANDS AND WILL COMPLY WITH n1.l,NON-POINT Alit HANDLING ONI'I'rr(1 IU INN(CLY 1 EE
SOURCEREGULA'HONS'. \
AB HANDLING ON] OV%ZA.NNI CFM) .......
RUC ON TAX
Signaturenf Appliumuc Comornor Date. EXHAUST HOLD OVIDUCT) HOUSING BrIGATIONFEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or thu re bonding occup int store or handle hmurdaus mmcrial HEATING UNIT(TU IIN),gX)BTU)
as dctlned toy tile Cupertino MaincieJ Code.Chau,' 9.12.;aid the Hcallh and SaI THAI ING ONI'I'(OVER 100,0001{1'U)
Code,Seainn 255J2(a)'!
❑Ye, CN,) VENTI LATION I-AN(SINGLE RES]Ip PAIL
Dam Receipt a
Will are.,Plica.,or forum building o,vi pant use e9mi merm no devices which BOILER-COMP(3111.OR 10(1000 111 U) /
mit h....Jnux air contaminants as defined by the Bay Arca Air Quality Management T(Yt. .
DI'llutP BOILER-COMP(OVER 1P(Lifi H'ITl)
❑Yes E]No
I both rend Inch ode,Sections
2 5 5.25533nou,
an ander Chapter f.95 oil,he.Cali-
Alit CONDITIONER ISSUANCE DATE
fnmia glow&Safely Code,Sections .that i 2553)vat responsibility
to notiynt Ilial if,nc NI3W R13SIUf;N'DAI.M1IIiCH. SQ,17.
oftW comintly have atenam.hlln,i,ismy uanesllot of rfifionwify,helancy. t
of hryuilemcros whiClt mus be net prior m issuance of a CaniOcate of(inlpuncy,
Owner nr nulharired ngcn, D'a,c TOTAL: ISSUED BY: fJ`
OFFICE look