S 0703APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUI'ERTINO aun.DlNr.-ELECTRICAL PC nr No
BUILDING DIVISION APPLICATION/InERMIT IgNC. PRNG. MP:Cu,NTIFIC O 7 O 3
RIItt n6G PRf11EfT FDF:\TIE'llATION
oL
NAME:
CONTACT. PHONE:
❑ Consultant Fm Paid by Appllwlt (Initial)
IJCIHSSED C'ONfRACTIM S DECIARAI'ION QT.
I berth' affirm noun 1 em IianaW unakr pmvixumx of Chl ref r) kar mcing
Z wish SeOim 71XXT)nf Divisionlaf the au,ite.a.m Tri{e>aioru Ctde.WmY lkrnois
in full furccard tP,
L'lanae Claaa / Lk.N
uVl D he C.,
d AI RITE . DECLARATION
Z I untkNund Iny gloss shall M used ur pu M1lic muWs
Rel Licensed IhMnxxea.l
OWNER -BUILDER DECLARATION
Q IIII , ffirran StOthatI 1. c.cmpltram the Como,❑',:ons A.mlaw P, he
�! which ng rtvson. lS.it 1 7031 re s. aMs caul P.fexxianr CNe: Any call s county
which, if, o • le N) to canwrun, dw, amproac, Jcmiblit t re repay any urvctart
Q� pr., hei, ivuenee,eo rtquirtx ml Nppliomfnrouch Corso In orns,le r Lw, --,poll - l
Ill., he is cte, s ua pununfiftifte al l"ut a ions ofa l Commdad Lll Prole Law lCbaptef 9
Ic.,h,is inp wish ScOficaraBI oe Its,.. tic, alb, destwftion. An, nCao)or
p� mal he is 31.5 b Hertfmm vd Je Ivsis res the weSCJ c.acml rn In Any l 1 --Rn of
ISN. Soman "1111 S by any applicnnl fnr a Iurmit suhjmx the uppLcvnl to o cell penvlty of
not marc (hon five hunalml dol Iwx
GQ I, as mrcr of mclaoperty. nr mY cmpkyeca with w9gex ya shear alga comprnratim.
will dothework, wdthe wmcmmixrlamastedora.five, rale(,Sec. 7D W, Huaatc"I
vnJ Ptafc, not CUJo'. 'llc C , IhmetNN Liccna.l do five, not apply m m trvmr of
pnrpmy wht Wikk pr impnwe,11eRan, and whu dtry such what himselfo erlfor
his own employees, pm`� Jw inch neem is wall
sue, on i)ear red ar MTctcd for
ole.,luiller witheW he harimpm rover, issold within ore yearofcampletiof tk
wncr-huiWcr will haw the burden of prtrving thvt Ireful m W ild to imryosc for per
rywc of call.).
C 1, as owner of the many. am excluaiwly cwwclilrg with uesiI conoacsan to
comtrvct the Ml (S.s. 71141. Bleurs,a sad Profesxims Cade:)The, Con.nona L-
cen. (caw tkxw nm elry+lyman nwrcr of Tropes' whs Feil&mlmpmventMrcrn. wJ QTY.
whoo-w mfmochprajecuwithaevnt tar(s)lke dp uvnstothe Conlnetelx
License law.
I am cxcmpl under Sec. ,H&PCfell thismc—
Oaf Dw
WORKER'S COMPENSATION DECLARATION
I haeM1y of . ua&, penalty of perjury are of the fiNluwing tkcleral'Xtm.
I haw anal will mvinlain a CerliGcwe of Conant m soft—inert tie Worker', Coogan
.timt,. rovidW ha by Section 37M of the lobar Cods. for He Mrfmmvrec M the
work far which than fermis is issued.
1 hem uM will maintain WmRds Compcnwuon Insurn, u. myuiml by Smarts
3700 of the Labor Cale, for the perfonwu<of the weA for which mix permit is'sesuwL
CERTI IICATE Or EXIMI"1'ION FROM WOR K Ii RS
COMPENSAOON INSURANCE
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIA NCFS - RCS IDEMTAI.
PANEM
UPTO 200AMPS
OVI7R 1000 AMPS
SIGNS ELECTRICAL
SPECIAL. CIRCUTUMISC.
TEMP. METER OR POLE INS-.
POWER DEV ICF_S
SWIMMING POOL ELECTRIC CNC
OUTLETS-SWITCHES-FDCIURFS
NEW RFSIIENMAL ELECIR SQ Er.
(This usetian nal runs be ctmpksal iflhm
e peul I. for. hundrei "Bases, ($ 111111
car It.,) (This
certify lhel in the lifinallocc uflhc work for which this lcmtit i. i.oual. I shall
na emplay any pvmn in any manner so es,, Femme aubjeel w the Worker' Cornier -
0 Z .tion Lemaf California. Will,
.Z o Applicant
NOTICE'10 APPLICANT. IL after nwking this Cenitievte at ExCuTbon. you should
beecarc wtb,I to thv WaYer'x Canpenwion prevkdtau of the Later Code. Part must
fordim cnmpll with such pit—i. or oris permit sMll be dcemed o valued.
CONSTRUCTION LENDING AGENCY
C.1 hereby vihrm bust there i.acrosuuctiml lading agency gctRY for the pafmmarcc of
LL. — the w'ak for which thin pemdt is iulleJ (Sec. 3092 Civ. C.)
O U I<ndcrs Nome
r U Iso ,AJfirn,
y 1 anify finest 1 have rtad Ni, applicwitm and slaw meso the sboe, iof.ian is
h corm. l agnc to canply with all city and cwn', oAlinena, std tl.e Iaws ¢Inning to QTy.
ei Z hullding cnnnmetinn, anal harehy aullKKnc rery nmtiv of thlr city to enter upon the
aMvenenlimcd gropers' far itv eetao f pur,olie,
(Win ,,. 10 ave. indemnify It keep hsndev the City MCupenitm against
Lai jud,breal , caws and expenses which they in any way wcrve a,jew, said Cary
ron"lie ce of W grail ing of this pcou I.
APPLICANT UNDHRSTANDS AND WILL COMPLY wrm ALL NON -POINT
SOURCE REGULATIONS.
Sigmmrt, of AppliculUCort rectel Owe
HAZARDOUS MATERIALS DISCLOSURE
WTI(the vpplicnm orfuture buildingtccit a— cr handle hderdtwa ncalerild
as defrcJ by IW Cupenims Municipal Cale, Chance 9,12, and 1W Ilnith anal Safeny
Code. Section 25532(n)'f
E] YIN C] No
Will the applicanl or future Wilding cccil uw yuipnern or devices wblch
mit haralloux au cmlami.. m dcaned by de Bay Arta Air Quality M1lnnagcnent
lnrics'
F-1 Ye,' [:1 No
1 how rod the Furudou+ tsmtaeala mry.'s antler Chapter 695 of the Calm
fume. HI & Safety Codc. Smitms 25415, 25533 and 25534. I utdctwnxl Ihm If the
Willing ddea not eurmrafy buvca III then II in my teq.nsiMlily to unify the taleoPart
of the, lGl WrtllenLa which flow lle al crla to lswdrFY of r Cend Ne of OeNancY.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & VIM- WA'IP.R EA)
BACK FLOW PRIM= DEVICE//--��
DRAINS - FLOOR, ROOF, AREAdaI ND
FIXTURES - PER TRAP
GAS - EA. SYSTEM -I INCA OM I=
GAS - EA. SYSTEW-OVER 4IRA) .
GREASVI N DUSTRL WAS H: I NTERCEPIOR
GREASETRAP
SHWER- SANITARY -STORM EA204)PI'.
WATER HEATER WIVENDELL'CIR
WATER SYSTENVTKIH TING
WATER SERVICE
NEW RESIDIiNT'IAL PLMB. SQ. FT
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,000 CENT)
AIR HANDLING UNIT (OVER 111,000 CFM)
EXHAUST HOOD ONMUCT)
I (HATING UNIT IID 1110,000 BTL(
HEATING UNIT (OVER 1011,0011 B'IU)
VENTILATION FAN (SINGLE RFSID)
BOILER - COMP (3HP OR 100.000 HTU)
BOILER - COMP(OVER 100.00 BTU)
AIR CONDITIONER
NEW RF_SIDIi Al- MECH. SQ, EE
OFFICE
SQ. IT FLOOR AREA
PArb
FEE DED .4 nn,
R Q, ET.
SI0RIES - IYPLl-ONLRUcntfr,
l C. GROUP APN
tlUI1.OING DI V ISION FF,F'_S
PIANCHECK FEE
ENERGY ITE
GRAVING ITE
50115 FEE
PAID
Uwe Rces,X N
TOTAL
BUILDING ITE
FEE SEISMICFiIi
ELECTRIC RE:
PLUMBING IEE
MECHANICAL FEE
CONSfRUCI'ION TAX
HOUSING MITIGATION FEE
PAID
Iliac RcaiplN
DATE
BUILDING PERMIT INFO
HLDG ELECT PLUMB MECH
p—
FEE
J013 DESCRIPTION
RESIDENTIAL
C ShDWI. C KITCHEN REMODEL
CADDITIDN [-I PLUMBING RF. -PIPE
❑MULTI-UNff CSIRUCTURAL
MODIFICATION
C INTERIOR CI CHIMNEY REPAIR
IMPROVEMENT [SWIMMING PoOIS
❑ BATH RI?MODEIBI-PAIR ❑(DEMOLITION
OTHER L.IL�;�—"7 11�•'�
COMMERCIAL
C NEW BLDG/ADDITION ❑DENIOLITION
C TENANT ❑FOODSERVICE
IMPROVEMENT
❑ OTHER
J i
SQ. IT FLOOR AREA
PArb
FEE DED .4 nn,
R Q, ET.
SI0RIES - IYPLl-ONLRUcntfr,
l C. GROUP APN
tlUI1.OING DI V ISION FF,F'_S
PIANCHECK FEE
ENERGY ITE
GRAVING ITE
50115 FEE
PAID
Uwe Rces,X N
TOTAL
BUILDING ITE
FEE SEISMICFiIi
ELECTRIC RE:
PLUMBING IEE
MECHANICAL FEE
CONSfRUCI'ION TAX
HOUSING MITIGATION FEE
PAID
Iliac RcaiplN
DATE