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CITY OF CUPF,RTINO ' ..- Tear.-- PER M1 NO. _
APPLICATION/PERMIT rl.uglmrvr,. a5ecunrvlcAL C n �'
BUILDINGDIVISION 1 rn n1� INe]risonmMORNTMCITION - JJ
y2o I Te I, rle T/ C- UNIT $1
LICI:NSEDCONIRACfOR'S DECLARATION
Cm2, Ihc0110), Divitin,3,41h, Rmirmkr Prov esofCCecla.l;smy feminism
tslOp Sationit%gpaf Divisionlnf sM1e Bmimss and PmfcssionsCnde, end my feminism
In
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Licfull ense
Clas effect.
<Vly license Clea Lic.p
CesEy U Conuwmr
ARCNITE.C1'S DECLARATION
ZFry
OZ I understand my prem shall be used u cord
Public res.
sF" Licmeen Professional
C pYg OWNER.RUILDER DECLARATION
yxO 1 hereby effort that I em eacmpl frmm the Cnntrador's License law fru the
LL134.yQ following reason Smibm 7011.5. Businces and Professions Cade: Any city m county
Om J which requires a permit to construct, alteL improve, demolish, m repair any structure
IwY� prior In its issuance, also requires the aWlicwl for such pemiuo rile a signed statement
tail tY<p that he is licensed pursuant to the provisions of the Cnatomor's License law Tanner
EE0.x e�' 9(commencing with Section 7001) of Division 7 of the Business and Professions Cade)
W—m sot his he is exempt therefrom..dthe bmisfee the alleged mantism. Any violation of
C�< Section 7031.5 by any applicant for, permit auhjectsthe.ppliunno• civil penalty of
O nn more than f ve hundred dollen (5500).
❑ I, as owner nfdle property. m my employees with wages as their sole compensation,
n will do the wok, and the structure is not Intended or offered for sole (Sec. 7044. Business
and Professions Cale: The Contractor's License law docs not apply to on owner of
prmmny who builds m improves Ihemm, end who does such work Cimaclror through his
is employees, provided that such impmvemenurc not intended or offered fm sole. If,
Mswevcr, the huilAingo Improvement is wld within one year of ennpinion,tire so'
ner-
builder will have the harden of proving that he did not build or improve fm purpme of
x)1, as owner u0hepro,rertnd y, aexclusively contracting with licensed contracons In
onstruct the projttt (Sec. 1014, Business and Professions ,esm)'Ihe _cninsitoa
License law rims not apply to an owner of property who builds or improves thereon, and
whncnnnocss for such projects with acontractor(s) licensed pursuanuo the Contractor's
License Low.
❑ 1 oro eaempt under Sm. , R k P C fm this rus�xl
770 O
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Owner Date
WORKMAN COMPENSATION DECLARATION
❑ I hereby affirm that l have a certificate ofmment to Ulf-insuu, on. artiftcate of
Workers Compression Insurance or o cartifsedespy, thereof (Sm. 1800. IAb C.) which
coven ell employee's under this permil.
Policy 8
❑..Cenifed copy is hereby furnished.
sOgjcnifed copy is Bled with the city inspection division.
CERTIPICATR OF E%EMPOON FROM WORKERS'
COMPENSATION INSURANCE
(This uc0. need nm be completed if the permit la Info.. hundred I tart ($,,)
or less.)
I certify That in the domance of the .,it her which this permit is rose 111, 1 shl
no son employ any perin any counties an as to became subjml 10 the ken'
Compcnsationlawenf C.1ifamia. Dale
Applicant
NOTICE TO APPLICANT: IL after making this Cenificate of Exemption, you should
because subject m the Wnrker'a Campenudon pnsvisiom of the I.M. Cade, you matt
forthwith comply with such Provisions an Ibis pmorit shall be deemed revoked.
CONS'BUCIION LENDING AGENCY
1 hereby efforts thus them is • eonome0on lending agency fm the perbnmance of
the wok for which his Pemtil Is issued (Sec, YOGI, Civ. C.)
lands,, Name
Lcoclei a Address
I rectify that I have read this appliu0ors and mim that she above Infnrmmino is
correct, 1 agree us comply with all city and county ordinances and state laws minting to
huildiagcunstramion, and hereby emhodae representatives of shin city menteruPon the
nMvcmcmimted prupeny for inspection purPmca.
(We) agree In save. indemnify and keep harmless the City of Cupertino ageiml
liebilisica judgments,cmteand expenses which may in my way accrueagaimtsaid City
in cnnsegy. , f iTw 7",
sVy� ^ r I I q
IIAZARDOUS MATERIALS DISCLOSURE
Will the applicant m future building meupenl more or handle hamolous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Cole. Section 25132007
❑ Yes ❑ No
Will the applicant or filum building occupant use equipment or device, whichemit
'smndo., Air cunomi Land m defined by the Boy Arca Air Quality Management
Nisuiell
❑ Yes ❑ No
I have read the haaardtms materials mgflomants under Chapter 695 of the
California Ilcahh & Safety Csa c. Sections 255115, 2551) and 25574. 1 understand that
if this, building dors nm currently have a ImanL that it is my meponsibility In notify the
Occupant tel the regniremenn which must be, mel prior to i.ssumm of a Certificate of
Occupancy
(byte, m..,Is iced agent Data
r. 5791ro 1 NA
PERMIT ISSUANCE
rnm
Dore
APPLIANCES - RESIDENTIAL
ION Dt
ai. w
PANELS
IJPO 2 0 AMP
201 - I AMPS
SO. FT. FLOOR AR1Ss
I�7y7
TTi
OVER 1000 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUR/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
VALIL
�T..� �!
g
VTLEfS-SWRCHES-Fl%TURES
NEWRFSIDENTIALELECIR _SOFT.
SIORINS
1:';.',`bC6ii11id6pNitP:gF.dr;>
, • .j'l�h
5t d�.Red,13? ,-. .
rnm
Dore
Recaipl a
PERMIT ISSUANCE
ALTER - DRAIN k VB -WA (PA)
N•. .s
SSI
BACK FLOW PR :CT. DEVICE
SANITARY
Y
R
DRAINS - DOR, Rotor, AREA, OND.
SCUCOLTA%
Y
R
RFS. PER TRAP
PARK IEE.
Y
R
GAS-EA.S 11i14-IINCAOUTLEIS
BUILDING(
GAS- k !M ... OV
PLANCIIECK RP.
GRP )USTRLW rENTE 1
GRADING ME
i TRA
SOILS FEE
1 1 ow—
ER A1NIj -STOkMFA. 200I7.
ENERGY FEE
Remits
la"loss"I
IN
TF.R SYSf NREATING
rnm
Dore
Recaipl a
NEW R rmTAL PLMB. SQ. FT.
TOTAL:
BUILDING FEE
SEISMIC ME
TOTAL:
EI.ECIC Fl1E
•MLCHANIC.AL PIdkwfiT
PLUMBING ME
PERMIT ISSUANCE
ALTER OR ADD TO MECI I. Tb
Mf.CIIANICAI, ME
CONSTRUC DON'TAX
AIR HANDLING UNIT (70 LOAM" CFM)
AIR HANDLING UNIT (OVER 10,000 CFM) if
to
1 1 ow—
EXNAUST I [GOD (WIDUCD
,�`
PAT[)
Data
Remits
I Ilia, nNG UNIT ('I O togWO B TU)
I (EATING UNIT (OVER IphI)[10 BI Ul
T01AL:
VENTILATION FAN (SINGLE RESID)
BOILER - COMP 11DP OR IMM) RTU)
BOILER - COMP (OVER UTTiT110 IT ru)
ISSUANCE
P A'
DATE.
NEW RESIDENTIAL MECII. SQ. PT.
ggs
FEB g�
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