S 1741 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUI'ERTINO BUILDIM;-ELP.C'I'RICAI, P1i I'1'NO.
BUILDING DIVISION APPLICATION/--ERMIT I-LUMPING-MECHANIC L 1741 "
BUILDING PRLJEC-I IDENI'IF'ICA'I'[ON
BUILDING ADDRESS: SAN]I'ARY NO, APPIJCAI'ION SORMI'TITL UNIT
zl-uA L11�� �qNF C �Jr�'i eK6 /716
OWNER'SH C:\n PHONE. CONTRA OR'SN I!: LIC NO, NIC C091 Rol..p
I A 0. /•V�s��J
ANCiII'I'I!CIIIiNCINEI!R; LIC NO: ADDRF'_SS'.
Jo �a e, 6RDTSG -!2, LJ I�t g 87
CON'I'AC'P. PHONE: ❑UII,IJING PERMITINTO
> ' ^ ElConsultant Fces Paid by Applicant Qniliaq nu)G El
rLUn1u mpcn
UY ❑ ❑
LICENSE:])CGNIRAcn OR'S DECLARATION I QTY. ELECTRIC PERMIT FF-F,
1 hemby aRm,that 1 dun r erned trade,provi......f Chapte,9(o-,mmoneing JOB DESCRIPTION
❑�Z with Section 800),!Divisinn Sof the Businea and Pndmsiom Cale,ondary license:. RIESIDEN'FIAI:
�1- in lull l'onsand effect jj 1�2 PBRMI'i'1\Sl1ANCE
�'J .�T /} ❑SI�DWI. - ❑KI'I C1113N NIib10DE1,
QUU Lwen'r Clues Lica APPLIANCES-RESIDENT[A]. ❑ADDITION ❑PLUMIIING RE-PIPI:
F-ZW Dam Counl'mm,
vsdm
ARCIII' '1SUChAItATION
❑v1CTl-UNIT ❑STRUC'IURN
EOy PANELS MODII§CAI'U,
NzC>
N Z I undealand m Alam-hull be u,ced v,pubis remrdn
O'Z t3 y UI'TO 2tH1AMl'S
❑IN'1'1!NIOR ❑CHIMNIiV REPAIR
F-4L_'OW Licensed Pude,,unvl , IMx1AMPS IMPROVEMENI. E]SWIMMINGPOOLS
dY�� OWNER-BUILDER DECLARATION )AMIK ❑RATII REMODEUREPAIR ❑DEMOLITION
uY Q 1 hereby alfa,that I ma exon,food he Cont ractorx License Law for the
d
if O W U um^IY ❑OTHER N
3 a ]i+Ilowin6 mann.IScuion 103 L5.Ilusinew vnJ I'mfession.Crdc:Any city nr 'IGNS !C /`
til W vFi which mquims a permit to co n.weL alter,improve,demolish.or repair uny%I —fes_ F±IDP
F=�dt no,1. rola mvnirex tMvpplicant to.wch ponan to tae asigneJ statensnt HCIA CUE' IS rl M')('1U /V t
thal he in licensed pursuant u,the provisions of the Contractor's License Law lChapmr �•--
�ap0 (commm�eing with Section l(00)ofl)ivi,ion3 afthe Business and Rofdm"iunx Cale) TP 'lIR COMMERCIAL:
a a 1bn he i.,exempt forefront and the naris fa the alleged over,
any violation of [INIiW IiLUG/ADD(❑ON ❑DI:MOLI'I'ION
Xnu• Section0031.5 by uny trphc:m.I...ale, rb,jv,s five opplic:nn lo n civil I unhy.l WER V TENANT' ❑POOR M71RVICE
W ti .1 inure In five hundred dollua($5011).
f ZdO I,ns ow,mr of the n SWIMMING Oh ELEC PROVEiMEN'i'
❑ pn,p_ y.or is mnplended wish offered for
r lhci„e.c.4. nu idv%n 'rllliR
F. willdntnc work.and Color: he Corchnen imm�dcdon,wdoesaot Tin,ec.II)la.owner
If
�3m and 1'n,lcsionx code:The Cnnwcn,h License how dress not appry In an none,or OU1hi515-50011 CITES- I RES
pmpeny who builds or,mproves thereon,and who does such work himself or through
his own erdplayea,pervidod that such:mpro.x,nems am not intended ar offered lot NEW RESIDENT IAL ELECT R S
sale.If,however.the holding.,impearavm is add within one year.fcompleion.the
SQ.17,FLOOR AREA LSQ.iI'.
owneu-budder will have the burden of proving that he did not Wild or improve for pur-
p,.e of sa1e.).
El 1.as ow net of the prope ty,Turn exclusively contracting with licensed contractors ,, T(y1'N.:
construct the project(Sac.70,44,Ilona ass and Professions C(rle)'I he Cnntrasvtofs I,i-
-clawdoe , Irp,ly loon ownerol'pr.peny whonoildsu ..........it....nn.o,d QTY. PLUMBING PERMI FEF.
,It ocone Tuck for ado omjum with n von....( nlfoo'ed To runnum Ino Cnnuaam',
license Low. PERMI I'ISSUANCE
zIvin cxan,pt undo See .li&PCli,r this rcannn
' O ALTER-DRAIN&VENT'-W 11!51 VALUATION
�"-VMJ t:SQ)MPI!NSAIION DECLARATION RACK FLOW PRO(f;CT.DEVICE Q ll 0
1 brainy affirm under penahy of perjuryane of thc Poll—i.,declarati.m:
�Ihave unJ will maicadou Cenififa fConsorn to-elLinsurt fur WorAcix Cnmpen- DRAINS-FLOOR,ROLE AREA.CON])' STORIP_S TYPE CONST RUCTION
nation,as provided for by Section 3010 of the Lab,Cale,for the Nuarr nonce of the
work far which Ills permit is Nared. MXTURES-E'ER TRAP
❑1 have Tund will maintain Worker',C....Ka.,m:on Insurance,as required by Section
3900 o11hc Lunn.Calc.folhe perituranceol the w,,,it fur which this pt,air ix issued. GAS-IIA.SYSTEM-I INC.4OU'I'LI.TS OCC.GROUP AI'N
My Worker's Co iponsati.n Insurance wrier dnd I'o11cy rardwr a,,:
Lltrr e: I'.IicY N"" GAS-VA.SYSTEM-OVI!R 4 LA)
CEN'1'IFICAI!OF I:XHIM I"P[ON FROM WORK ERS' GREASI%INDUS'I h WASTE I NERCEI'IOR
COMPENSATION INSURANCL' BUILDING DIVISION FEES
(I'hinsmutur owed an,bcmmplemd iflhc pernitix fonmcnundral J.11arn lS llA) GREASETRAP
1'LANCIIECK IEIi
.r lu .)
Loy an,
inthe pedrunnerudtheas,rkfor illichsubject
this the Wani,Ta Coishell SEWER-SANITARY-STORM EA 200 W.
not nnpiny any person in any runner so as m Mcnme sublet m the Worker:Compcm ENERGY Hili
Z -tion 1-to—of California.Dave WATER NEMER W/VENT/ELECR
z Q Applicant GRADING FEE
N(YI'ICE To APVLICAN'1':If,after omking this Certificate of Esemp:nn,you should WATER SYS I1!MG RIATLNG
t_ SOILS Ila!
H dee lossuhjcct to the Workers Cmnpenvnion provisions of Lnhur Crvle,yon mull
a Q f adiwitb can,),with such pmvkiou 1)hie panel Shull be deemed invoked. WATER SERVICE
CON S'IRUC'I'ION LENDING AGENCY NEW RESIDEN'I'IAI,PLMR. SQ.def. U717.
I herehy uffrzm that In ucnnsmmtion lending agency fa tine pI,f...alme of a
�O the work fn which to,pc Iran ,issued(See3009.Civ.C.) t
C) 11----x' lender',Nuns TO'ITL:
U Lcnder'x Address T(ylAh:
} d I certify tha 1 have mal this application and sats that the above infunnmion a BUILDING
F y carrot.l agree to comply with all city and county drdinanm,and state laws relating, QTY MECHANICAL PERMIT FEE
U Z nuildingcnntmction,and hereby authorize representative-ofthi.cify tnanaer upon the
abwnnncminned property far inxpeoion pnrp,se,. PERMIT'ISSUANCE
1 Wc)..jace to save,indennlly and keep lumnlu,-me City of CnPertino aguinxt
fnbifflo%,julgasnu,wxRand expense,which Indy many way accrue aguinxt snit]City AIA ER OR ADD'IO MFCH.
-cq,¢ncc of Inc grun(ing.I iblx len mit.
AITUCAN'f UNDERS'LORDS AND WILL COMPLY WITH ALL NONH'OIN'1' AIR HANDLING UNI'I'CIO 10.11101 CIN) MECHANICALI 'li
SOURCE!REGUI"A'IIONS,
AIR HANDLING UNI'r(OVER 110,000 CFM) CONSIRUCI'ION TAX
Sig, um of ApPlicanl/Qmtmmor Dam EXHAUSTIIOOD(W/DUCT) HOUSING MITIGATION FEE!
HAZARD - MATERIAISDISCLOSURI!
WilHhe applicant an future huilding mcupomnlom or handle haaodous mutedrol HEATING UNI"1'(TO Ilk."BTU)
as t'S-s by she Cavernous,Municipal
VEN
unicipul Crude..Chapter�9.�?.+red the Ileal,h and Safety f1RATING UNIT(OVER 100.000 BTU(
ak.Suainn 255321v17 /
-so
IIAUON PAN(SINGLE RESIDE ('AID
Umc Racipt p
Will the applicant or future building uccupual Use equipment adev tors which ❑OiLI!It-COMI'(3HPON 100,000 BID)
unit hazaNnu,air on erna naniIn'deli Isd 1) t�her Huy Arcu Air Quality Munugcnmm :U
Dsirinl IIOILIiR-CIIMI'(OVI!R 11011X1(1 Ii'IV1
❑Vn �' l
I have mad the ha,ation,nationals requirement,under CMpter 6.95 of The Cali- AI N CON Do I'IONER ISSUANCE,DAP
hard. (;
Ilc,hh&Safety Order.Sections 25505,25533 and 25534.1 undcr and than if the NEW BESIDES AL MECH. SQ.PR I 9 L
hniltingd«s no urmnI h,vc a, anuhat it ismy msp,mibilayn notify thcoccupant
",the
msryi a which moa h amt I+rior m i>,vamc of a Cenilimm df lhcupuncy. . `
Tor uuthoriecd agent Ute 'IOI'AI.: ISSUEDBV
OFFICE
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