S 1654APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CLPY QF CUPP]RTINO [lull 1):NG-ELF,C'I'Ric' L PEgITNo 1654
IIUII,DING DIVISION AI'PLICATIONA'IiRD11T ,slur Da 0]InIND-MF.(:nANIGu,
. PYN:: 1"1' C`1,IANI FII' AT11)\
NAMI-
_ ❑ Commi ant Fees PL Applicant (Initial)
LICENSED am licensed IORunder prDECLARATIONiL,Ifhap QTY. ELECTRIC PERMIT
1 M1erehy nRnn that I um licensed under pnwisinns of Chapter Y (commencing
with Section 7") oflAmdon 3oflhe business and poncenaions Code. and my license is PI:RMfFISSUANCE
in full farce and effect.
IJar¢Clasa Lic.s APPLIANCES - RFSIDGYTIAL
ARCHITELTS DECLARATION
1 uadersmnJ my p];,,,,,hall be used as p.hire retrad,
Licensed Professional
(OWNER -BUILDER DECLARATION
1 hereby aflimt that I am exempt from the Contractor's License Law for the
fallowing reason. (Section 7831.5. Businos and Professions Cody. Any city or county
which requires a permit be construct, alter, improve, danolkla, or repair any ,mcmre
prior o its issuance. also requires the applicant for mch Permit o file a signed amement
(hilt he is licensed pur a antro the provisions of the Contractor's License Low (Chapter Y
(ennunencing with Section 90IX)of Div m Sot 0e Bovinessnnd Poor ..or Codd nr
tout he is exempt dietermm and tic hast, too the alleged umnpaim, Any vlolmion of
Section 7031.5 by any applicant fora permit brul"," the uPPI-Com m to civil penalty of
„ more man five hundred dollars D50q.
❑ L as owner of the properly, or my employees with wages as their sme compensation.
will do the work, and the structure is not intended orolfered for old(See 7014, Business
and Profes>ions Cod, Me Contractor's License Law dons not apply m an owner of
property who builds to, improves (hereon, and who mc, suchwork himself or through
m
his own employees. provided that such improvements am not intended or onered for
note. LL however, the holding or improvement is said within one year of completion, me
nwi fir -builder will rise me burden of pro ing that redid not huild or ineprove me par
pow of v
❑ 1, as owner oexclusivelyn
the proper, am exclusively cnrnaing with licensed comma ll, to
nastma mep adem (See. 7144, Ravine, and Pror,oamrs Cale:) The Cnmracmra.i
-
meLowdoesnutapplynroe,
e an owner of pperly who builds or improvtheram. and QTY
who Courter, for such projects with a comrwhorb) licensed pursuant nt the Contractor's
License law.
(] 1 am exempt under Sec. .B& P C file his mosnn
PA NHE S
11,'10 21 NI AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/M ISC.
I I',M 1'. M H 117 OR MOLE I NS1'. Q
POWHIR DFVICeS n> i
SWIMMING POOL SW POOL ELECTRIC
OU'rLISTS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELECTR SQ ET.
WORKERS COMPENSATION DECLARATION
1 hereby u0irn under reality of perjury ane or are following dcelamtion,
(] 1 have and setts mnimain a Cenilicale of Conwm m sell-inmre for Worka'x C...ari
cation, as provided for by Section 3]11) of the Labor Code. for the performance of the
work for which this pdrat is issued.
n I have and will nminlain Worker's Compensation Insurance, as required by Section
3710 of me Lbor Code, fertile perfnmt er ec of the work far which this lemur is issued.
My Waders Compensation Insurance carrier and Policy number are:
Colonel Policy No.:
CERrIFICATEOFE EMILE ION FROM WORKERS'
COMPENSATION INSURANCE
(This section need nal hecomplacd if the per iii Is foronc hundred Jollurx (SI001)
or ksv )
(certify that inthe Performance as tworkre which this permit isileal,Ishall
not employ any perxve any manner so as rte become subject o the Workers Compere
OZ shoo laws of California. Dam
Z O Applicant
!n
NOTICE In APPLICANT: If, after making this Cenllicam of Exemption. you should
libelant, subject m me Walkcds Comp .... pct siren of the lahm code. rat toss(
fnnhwi , comply wish such pm, '' n,n this Imrn t dart be deancJ ocvnkal.
Q
7Z CONSreisa RUCTION Ltion ING lending
U Ifhereby .1ach this mere ixacialScelionle. int agency for the perfonnanee of
Uo E•' the work for which this pcamig n issued (Sec. 3119]. Civ. CJ
Q U Lenlels Name.
} {17 IsnJcrs Address
1 ca,arc (hat I ply rill Ibis application and slate that lad umle law,
ix
r h lain I agree to eonlEst will sell city and seamy nrdlnunms and lama lawn lire t e QTY.
U Z building umsanm(iun, nuJ hc�yuuthnnw rgemmnm(iv., of lbiwilymcnlenynm lbs
uMwcanmtionc,[ togmny for ano,vt on Purpexnx.
(We) agree to eve, indemnify and keep harmless the City of Cupcnino ngaina
labilities,judgnmms, costs and Cori which may in any way accrue against said City
in onsequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILT, COMPLY WITH ALI. NON -POINT
SOURC -R "GULM[ONS. /q
Sabaatom of Applinmt/Contractor ITnc
IIA'/,ARDOUS MADiRIALS DISCLOSURE
Will the applicant or future huildog dneupunl,ore nr handle ha/mdouu In,amiul
C,
defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safely
Gds., Section 25532(x)]
❑0 Yea o
t
Willl the apps icon( or future budding overlong ase equipntem ar devices which
ani( hasndnus it cnnwminans as defined by the day Area Am Quality Munaganent
U ldicR
E] ye,
1 have mud the hvandvs materia, ax,o rumemx rude, Chapter 6.95 at the Cali-
famis 1lcalth & Safety Code Sections 25505. 25533 and 25534. 1 moldboard ghat if the
boadingdoes nm curmetty have a teacher, that it ismy resryemibilay ae reify the woup oto
PLUMBING PERMIT
PERMIT ISSUANCE
ALI ER -DRAIN & VENT- WATER (EA)
RACK FLOW I'll"' ECT. DIiVICIi
DRAINS- FLOOR, ROOF. AREA. COND.
FUCE ORES - PER TRAP
GAS - FA. SYSTEM "I INC.4 OUTLETS
GAS -ITA. SYSTEM -O VER 4117&
CREASIYINDUSI'RI. WASTE IN I'IiItCEPTOR
GREASL'1'RAP
SUMER - SANITARY - STORM Rix, 2118 FT.
WA'I ER HEATER WN[NT/ELEM R
WAT12R SYSTEM/r'REAI'INC,
WAI'EIR SERVICE
NEW RF_SIDENTIAL PLMB. SQ. IT.
MECHANICAL PERMIT
PIERM I I' ISSUANCE
ALTILR OR ADD TO MECH.
AIR HANDLING UNIT Gro 10.00 CFM)
AIR HANDLING UNIT (OVER 111,(0.0) CFM)
I?%HAUS I' HOOD f W/DMC1)
H FIVIANG UNIT Q'O IPdId0 01H U)
HEATING UNIT (OVER 100.0110 It TH
V EN'DL.ATI(ON FAN (SINGLE RESID)
BOILER -COMP (3HP OR 100,000 BE
ROILIiII - COMP OVER 100.000 If I U)
AIR CONDI HONER
NEW KESIDENDAI. NIECFI, SQ. FT.
OFFICE
LIE
y(00 .'D J
PI11LIy1NG [)[VISION PEIi o
PLANCHECK FEE
ENERGY ITE
GRADING hili
SOILS FIJI
PAID
Ulm Rccoipl a
,s HCH.DING hili
IFI: SEISMIC trip
ELECTRIC ITE
PLUMBING FEE
p 1 1ANICALFEE
PAID J l8 oY^I/G
Urge Receipts
ISSUANCE DA'Z'E O
ISSUED BY: J'oe
BI.DG I.LFLI 1.1.11.11 MYA,X
❑ ❑ ❑
PEE
JOB DESCRIPTION
RESIDENTIAL
❑SFDWL ❑RETCH" EMODEL
❑ADDITION MBINGRE-PIPIT
❑MULTI -UNIT [I STRUCTURAL
MODIFICATION
❑IN'IPRROR ❑ Cl H EANI3Y REPAIR
IMPR(OVIIMI!NT 0SWIMMING POOIS
❑BM11 RHMODEI/REPAIR ❑DEMOLIHOPE
❑OTHER
COMMERCIAL,
❑ NEW IILDG/ADDITION ❑ DEMOLITION
❑'[ENANT' C] FOOD SE VICE
IMPROVEMENT
❑OTH17R
1
/
SQ, FE 11-OOR AREA
SISQ. FT.
FEE
y(00 .'D J
PI11LIy1NG [)[VISION PEIi o
PLANCHECK FEE
ENERGY ITE
GRADING hili
SOILS FIJI
PAID
Ulm Rccoipl a
,s HCH.DING hili
IFI: SEISMIC trip
ELECTRIC ITE
PLUMBING FEE
p 1 1ANICALFEE
PAID J l8 oY^I/G
Urge Receipts
ISSUANCE DA'Z'E O
ISSUED BY: J'oe