S 1584�C
a3
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUI'ERTINO BUILDING. - FLECTR
NUILUING 1)I VISION API'LICATIONIPERMIT -,,, PI .11 R 1.0-n1RCllnl
4 Do
CONITCf:PHONE
Pei Pd A/ ekt e -Q!-113 &
LICENSED) CONTRACfOR'S DFC1ARA))ON
I hereny affirm that I not licaucd Under Prnvlxnnv of CTopty 9 (—Marcos,,
withSttli...9fXXDof Division, 3offlo Halinus andProfessians C- 6 0 9, J yliccnwlx
in full Banc ami eRat. C ��'hhFF' � �
liccnw Clw lic.�
ARCHn`iCI-S DEORATION
IunJux"adnn plant. doll be u.wd m public record,
r,
D RACIOR'. AMI'.' to ✓I J
Ljr
All 'ESS:
I T t r�
❑ Cnneultant Fees Paid by Applimi t (Initial)
QTY ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
1'ANFI S
UPTO 200AMYS
IIWNER-BUILDER DECLARATION
I hereby affran tha I am creme from tk Crmtmcre'x Lic<nw Law for the
following mom. lot,, mo 70315. Be,inu, and Pmlelannx Crak: Any ill lar emmy
which "air, o panni, to cnnetmet. tiller. Ihn,sol , denrgish, w reform, dmcla,e
prkr to its issumw<, tihu rtyuira the aWlic-ant f« such Permit to File a signed srmemrnt
da k is licenvd Elemental to the pmvixvn of tie Cexurana's I nlosti a low lcbynv Y
brommeneing with Sectixm 9000) of Diviawn 3 cat the Business and I'mfo,nms Ode) or
Jet k is cl arytt merebarn and the k,is for Ik slkgcd cxemptinn. Any vmleiun el
Sar inn 9031.5 by any rPPI icrnt for n Perron wh'Mu,x Ik wtplkvn( to a civil parody of
.at Uma Than rise handled dollws (SNP).
I, as owner of de Prnter , w my emplmecs with wages e, their sok ctmpen.i
will d, the work, and the mactere is not havnded or Mfcred fee sak I.Scc. AW. ... I—
and Prodsvions Cldv: Thi, Contnctcra License, Ino dour nm .Orly to an owner Uf
,,en, who hsuds or bnlmtve, dcoaw, andwho,,,, mch wind himwlf or 0fnefgh
his win cmplrycw, rovitkd slut such impenvcnenrs arc ,lot imcnkd a nre,c] for
ole. if. htwel rhe building w in,rove tent is wild within arre scar. of rnmplchar. the
tla.hadde, will lus'e be burden of I'rovin, thw his, did rot In iM or imlrtm< fm pur-
Pow of oIt.),
C) I, as usoor of lila prnperi, all, exclaoively contracting with liver" contractors to
con'tmBusi
octlor
cb thedmshat(Sec.o an matter
eror redodyw rex Gdrmrso:Cwdvool and scLaw commibr sash ras ytorn ift..menfiverbn boilersfam, intlaov r, dcmm.aml tjTY.
who cwamn IM warn pmjccu with a cwgrrw(,) lianaed puAuanl m the CmbuacUi s
]c Ino.
[la
1 um enema order Sec. . H k PC for thu ruubn
Cosner Doc
• WORKER'S COMPENSATION DECIARATION
I thereby affirm attract pevlty of perjury one sai following Je<lararitxn:
I have and will muinmin a Ccmfcatc of Con.senuo adt-morre f o Wtai Ys Ctmpcn-
,,allnn, a, pruv.tic] to, by Se,Jon 391X) of blc ILJrr Crkc, for the edimercc of the
wwl fisc which this perm, is issued.
0 1 nave and wJ1 maintain Worker's Comlcnsmitan Emotional. as "hirN by Snnion
3700 M the Labor Crus, fame Ktmna a of the owl for whichthis permit is issued.
My Workers Compenotion Insurance cortins and Par icy numkr art:
Cimicr Policy No,:
CER)'IIUCATE Oil EXEMPTION FROM WORKERS'
COMPEN'SAI'(ON INSURANCE
(Ibis retire rbe<d na k contpktM if Je prnnit u fworc ktXlml tbllarx IS D))
m),,,,)
I c<nifytkt inlMperfam ueftk wind Erwhich this pcm,it is issued, I shall
rep nnploy any ermn in any on or., ,; n� hjE WhT W(nkvrs' CnTlen-
n
schrLow. f Colifcmia Dare /H fY"
NOUCE T6 APNJCAM': If, a n nulin s Ccm be empivn, ynv should
a NT subject to too Work Y, Compcnsminn envisions of tk I,nMrt Calc, you must
fonbwith amply w11h noun pn,.,i,00.,,Thin ocr oil skill Is, treated revoked.
Q
5 z CONSTRULTION LENDING AGENCY
U O I hacby affirm tMt nem is nrtuructian ing agony tar the
thwars,
perforrtwtcc of
F e wd fw orwhich tri, perLsmit is ucJ (Sec. JING. 9. CCiv. e)
O0
U handerName'Name
InnJcrI ready
e docs
1 cligat tow base te'ad di, city
load cetm y ,rete that the ohtto l informations, is
Cn cunmt.lagrtemcomply hirebysu onus ct,ro nNituna<emd sum 6war u,nmgm
U z kiWingcrdinni:e.and krtbyawtbtnacrtec,cntwives Mthis airy to enter uem She
uMrvc (We) ,J ffoTo ryr me. i inormtion pm p bar
fWc)egram event indnnnify adkc.T bay de.into wCityof Cutemnsa! iorl
City
lirbilhi�n,j W gtt4 to coals and expenses omi. may in toy way carve against nalJ City
n Pusey NIT of Jae gSTAN S di%AN permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE R[GUTA)'IONS.
Signature of AMboant./Comeactor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the oWlicant normal, hrodding MNleat stare rehandle haienlous material
ev doth ibad by ,hc Cupcmno Munidlal Calc. CTfaecr 9.12 tint bk IImM and Swcty
s Gak. Sa'Jnn 25592(x)'!
C] Year ONo
•Will the applicant or frldr, building rucuptint use ryufpmenl or deices which
emit lo'rerdnv all mnwminans a, de incl by the Boy Area An Qw1iy Msmgemaa
DimnO I
❑Yes [-1 No
1 have tMasrdnus matenda rtmc
gairtma under Chaeer 695 nd t'In,Call-
fears I IcaIIM1ed tk Ne Safety Ode. S'edibrn 3NM, 2551} wJ 1554. ands a,aM thw if bk
building,kes not aaremly have :L mbmnl. Ino it is my mremsibility Io rmany the occorynt
of Jr nquitvtxnu which must k met elr m i.rwarm oto Cutifcwe of (kcupmuy.
SIGNS ELECTRICAL
SPECIAL CIRCUITIMLSC.
TINP. NEER OR POLE 1
POWER DEVICES
SWIMMING POOL ELE
OUTLETS.S-SWITCHES-,
IT
PLUMBING PERMIT
PERMIT ISSUANCE
Art CR- DRAIN be VENT - WAI'BR NA)
BACK FLOW PROTECT. DEVICE
DRAINS -FLOOR, ROOHARIA, COND.
121X TURES - PERT PAT
GAS - EA. SYSTEM -I INC. a OUTLETS
GAS - EA. SYSTEM -OVER J (HA)
GRPASMNUUS)RI, WASTE INTERCEPTOR
GREASETRAP
SI W ER -SANITARY -STORM IIA, 200 PI'.
WATER HEATER WNFNDELECfR
WATER SY.STIJ STING
WATER SERVIC-H
NEWRFSIDENI'IALPLMH. SQ. Ff
TUTAL
QTY MECHANICAL PERM IT
PERMIT ISSUANCE
FEE
JOB DESCRIPIION
RESIDENTIAL
❑SFDWL
"S't"" 1584
❑ADDITION
❑PLUMBING RE -PIPE
SANITARY NO,
❑S UCTURAL
APPIJCA'HON SUBivri II�AL
MODIFICATION
92
NIC
CONTROL
134
❑ BATH REMODFBIREPAIR
BUILDING PERMIT INFO
O(TIHFR
BLDG
ELECT I'Lu MITCH
AIR CONDITIONER
FEE
JOB DESCRIPIION
RESIDENTIAL
❑SFDWL
[I KITCHEN REMODEL
❑ADDITION
❑PLUMBING RE -PIPE
❑MULTI -UNIT
❑S UCTURAL
HOUSING NIGHGATION PTE
MODIFICATION
❑INTERIOR
El CHIMNEY REPAIR
IMPROVEMENT
OSWIMMINGPOOIS
❑ BATH REMODFBIREPAIR
❑DEMOLITION
O(TIHFR
BOILER-COMP(OVER al.001BTU)
AIR CONDITIONER
ISSUANCE: DA'I'S
...,m/.... V ✓R 'q d"
IL
COMMERCIAL:
O NEW BLDCJADDITION
❑DENouDOS
Cl TENANT
❑FOODSERVICE
IMPROVEMENT
OOTHER
SQ, FT. FLOOR AREA S/SQ. FT.
IEE
VALUATION
STONIFS TYPE CONSTRUCT
BUILDING DIVISION FEES
PIANCHECK FIJI
ENERGY M. 7
GRADING FEE
SOILS FEE
PAID
Date jrt'ei X
TOTAL'.
BUILDING FEB.
EEE SEISMIC FEE
ELCC Itic IEE
ALTER OR ADDTO MECH.
PLUMBING FEE S
AIR HANDLING UNIT ITO 10.100 CITU
MECHANICAL ITE
AIR HANDLING UNIT OVER ❑t,IXXI CFT9)
CONSTRUCDON'I'AX
EXHAUST HOOD (WMUCq
HOUSING NIGHGATION PTE
HEATING UNIT GO 1IXhIXMI HTIH
I HEAPING USE I(OVER I IX%RX) BTU)
PAID
VFNGLAI'ION FAN (SINGLE RESIDE
Hart Rcc<iptl
HOILER- COMP(THE OR IIXI," BTU)
'MITA
BOILER-COMP(OVER al.001BTU)
AIR CONDITIONER
ISSUANCE: DA'I'S
...,m/.... V ✓R 'q d"
NEW RESIDIN'TIAL MECH. SQ IT
TOTAL: