99110168 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 47471101 4,
CITY OI'CUI'ERTINO RUILDING-ELECTRICAL PERMIT
Itxu.UING UI VISION APPLICATION/PERMIT rT.uxunrvr.-ntEcxnrvlcAt. -
:.4 r•dtU11.U1NG 1'RO,IECT IDF.N'1'INICA'CION
BUILDING ADDRESS' INICIAkY . APPLICATION$NtMI'PfAh DATE
Y,.
OW6S ME:� PHONE: CONTRACTOR'S NAME: LIC N(l:
v n ///...C(lNl'H(ILp
ARC '/P GINEER: LIC NO'. ADDRESS 7 O
CORTAc'll PHONE: BUILDING PERMIT INFO,
❑ Consultant Fees Paid by Applicant(Initial) BLDG Elam PLUMB MECH
LI IINSEDC IRACfORS DECLARATION QTY. -ELECPRICPERMIT+ � 'FEB ' �/ IJ
I hereby affirm that I am 1 canted d p n s of Chapter 9(come ing _ ( t.'. JOB DESCRIPTION
In
�a2 hh Setion7 goof) oa3ofthe Budd: f is ndmylice . I
µ1 I'[RMIT ISYUANCI
FOO atoll torrential atter � )WI. ❑KI"i'CHI:N kEMODFa.
License C n Lic.M
<-U
APPLIANCES-RESIDENTIAL El AUDIT ❑PLUMBING RIiPII'F.
f-2m Done=Can DEC
m66 ❑M111.T1-UNIT ❑STRUCTURAL.
FO escram,camea DEC PANEfS
2 y,2., I undewand my plans holt ne u+W as pu,s records HIMN LION
02-0 UP'f0211(IAMPS ❑INTERIOR ❑CHIMNEY
REPAIR
a to It:u� Liver snl Professional 201-1000AMPS - IMPROVEMENT (]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER I(qO AMPS El BATH REMOIIELIREPAIR DEMOLITION
CC6 1 hereby affirm That 1 a...exempt fnna the Continent'.,Llanxe Law for rhe
LU following reason(Section 7031.5.Resines,and professions Code:Any city or county SIGNS ELECI'RICAI. ❑O'1'fIER
fw 3 u,iyQ"' wMeh wa,mms a permh m conccrow,after,impn,ve.demnlnh.or reVan any In;eture
F'yOJ prior In its Hsnoncnamoreyuires theapplicen torslo,lb, ou m flea signedudtemeat SPECIAL CIRCUI'UMISC. '
ythat Ile is licensed pursuant to the provisionsofthe Contractor's License Law PC utpter9
,X C (commencinS wiOr Section 0001Bnf Uivision3of one l3usiners and l'mmssimrs Cddo)nr 'cGMP MxfUR OR POLEINST. COMMERCIAL:
a a e C that Int is exempt thercfmn;and the halts for lw alleged exemption.Any violminn of ❑NEW BLDGIADDITION ❑DI?MOLIT'ION
m
Section 703L5 by any applicant for a permit subjects the applicant 10 n civil panvlynf POWER DEVICES El TENANT FOOD SERVICE
F, of more rhes live hundred dollars(5500) IMPROVEMENT
=p ❑1,us owner of the prapny,nr my enrpl0yces with wage,.as thcirsole campen,mian, SWIMMIp'G POOL ELECTRIC
Sa pr will do the work,and thesweare is not intended oto@red for sale(See,7044,Business �G'ITiER
µI m and Professions Clock: The Con actor's License Low does not apply to ua owner of OUTLETS ITCfiES-PIXILRB
A' property who builds or improves therwn,and who does such work himself or through -
his own employees,provided thin such improvements sure not intended or Offered for NI?W Rii EN'HAL ELECTR
sale.IL however,the building or improvement n,old within one year of cpmpleion,nhe SQ.IT.FLOOR AREA SISQ.Irl'.
owner builder will have the burden of proving that he did not build or improve for pur- _
orlam.), 9 9
71T,as owner of the progeny.am exclusively contacting with Incensed canvndm,nr TOl'AL:
sommoo the......I(Sec 7044.lomine,aild P f:.ons Cadc)no Commet L' - - -
c L d tapply toanowner ofp pert 4u builds or improves dencon,and QTY.',;rs '' PLUMBINGPF:_I "FEE • 8O
who nt ts for such projects with a conn t Olensed pursuant o the Counselor'sr
License Law. PERMIT ISSUANCE
I am exempt under Sec. ,B&1'C for thi.a reason
Owner D:Im
AI TER-DRAIN&VENT-WATER(IiA) VALUATION
20
Wm and COMPENSATION DECLARATION RACK FLOW PRfYTEC'1'.DEVICE 3qi 0 I to i? �
er
• IherubY othunderr Penalty of perjury one of the following declarations: -
IhaveandwillmanumnaCertificateofCorwatto xelf-imure for Workers Confirm DRAINS-FLOOR,ROOF,AREA.COND. STORIES TYPE CONSTMUCI'ION
cation,as provided for by Section 3701 of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
El I terve and will maintain Worker's Compensation Insurance,as required by Section
1700 ofth rccde,ln thegulf(99�Ie1'rp ceofthewnrk for x hichl ' gmjitsollied. GAS-FA.SYST1iM-11NC.4i)U9l,E'I'S OCC.GROUP APN
My War Can cuseionl `f.J r licya an c un�/ • .. -
-uner. 'V k.C.V`� GAS-EA.SYSTEM OVER 4(EA)
C '1 ATE 01:EXEIv 41'RQry,`Ipp�WOR F.RS'
.� A GREASOINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
71y
ne o ec t»hJ y�'/�'/'//ryy��ngl/Adnllam181(gB GItF.ASL'fRAPar less)lth tped'umence oft awork for�uIac rM ltiS ger//mull issued* .hull i'LANCIIFCK FIiR ,
moI rn to un manner sous to hasour,ub'�ne the Workers'Com SCWI?R-SANITARY-S'fORM EA.200 PC' ENERGY PRI1
p yany iCh I in Y' lu 1'e+I'
svtion Laws of Culifomiu.Dam WATER HEATER WNENTiTLECfR
z Agpllcant ) GRADING FEE Md_
W NOTICE TC)APPLICANT:If,afle making this Ccrifcme of H,emptun,you should WATER SYSTEMIIMEATTNG ^
a becvrme.object mile Worker's Conrpensttion e
provisions oI the I'lin Ce,You mud SOILS 1A •'
fonhwitb comply with such provisions onhis permit shall he dcemedrevoked. WATER SERVICE
Q ' II
CONSTRUCTION LENDING AGENCY NJ: RISIDIdN'1'IAI.YLMR. SQ.I*Il PAID
U0 (hereby nlRnn thnuhere isnmm�mminn lending agency forthe perli,nnnnce of Ua
14 — (hewnrk for which thus pemtit is issuW(Sa.9f19),Civ.CJ
U Landers Name TOTAL:
LLl Lenders Address TOTAL:
y I caddy than I have read(his ngpliwtinn no orae the the above infiltration is - - ROIL I G AEL'
(n correct.l agreem comply with all city and county ordinances and state laws relining to QTY. NIECIIANICAC PERMIT FEIi I pp
V ,7Z. building mainuction,and hereby amhoixe representatives oflhis city to enter upon the SEISMIC'PI?E�•--^•^--�-- -._.W
.NrveanennloncA pmpeny Int incgecninn purpnsas. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Clusters,against ELECTRIC EEG
liabilities,ju meats,costs ad expenses which may in any way.,me against said City ALTER OR ADD TO MECH.
in consei of the Building of this permit. PLUMBING FEE
APPLI UNDERSTANDS .L AND,W COMPLY WITH AI L NON-POINT AIR HANDLING UNIT(TO 100)(0 CPM) MECHAN ICA(.FEE
SOU 'E "RIJ ATiONS. ,y
71 41 AIR HANDLING UNIT(OVER 10,000 CIM) CONSTRUCTION TAX
Sign n AgplicanUComracmrVale EXHAUST 11001)(W(DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle harallous material HEATING UNIT(TO 100,1100 BTU)
a,defined by the Cu,mhm Municipal Code•Chapter 9.12 and the Health and Sally
Cade.Sa(ioa 25532N)^ HEATING UNIT(OVER PfA,(1(I(1 BTU)
❑Yes VENTILATION FAN(SINGLE RISID) PAID pate Receipt IT
Will the applicant or nrcbuildingoauupan(usa nqulpmenl or dcvicox which gO1LGR-COMP DHP Gk IIp,BIq BTO)
emit h1zxld9ua air con lmirmnls as defined by the Bny Area Air Quality Management TpT
.. Lo�thah
BOILER-COMP(OVER IN)NX)BTU)o
d the hamrdom netaials requimments under Chapter h95 of rhe Culi AIk CONDm(lNfiR, IS$UANCE DATESafety Cdwk ?550525and 25534.1 unMatnnd the if the NEWRESIDENTIALMCCIL SQ.FEurtendyhu "O"a" adavidniliy tif0cupantm hi st m r+mwccoPPi+at OrT(YI'AL i •dngcnl ValeISSUED BY:
OFFICE