S 1713 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUHAJING-ELE:I RICA I. PEH IT NO.
RIJII.DING DIVISION APPI.ICATION/PERMIT PLILMBING-!IITJIANICAL 1713
(WILDING I'HOA!cT IDES71'ICA71'II IN
BUILDING A�S�D{{D''''R�)EsSS: /�aa� y/���� ��y 45-0
�� f� SANI'T'ARY NO. A/PP/�LIICAIION SUBMIT FI(AL DA'I
'L�'T7� w01 co 'V�0 (l W4A
OWNH :S A 1E 1 Par li: �� y CONIRACIOR'S NAME: LIC NO'.
N NIC C��U�N'IROLa
.RCI IIIECI'/ENGINEER: J -LIC N): ADDRILSS: ❑ {/� r`
N'TACIS 1V PDDNH: BUILDIN�GGPPER�M[TINFO
L !L '.A -1 ❑ Consultant Fees Paid by Applicant(Initial) LI r ELECTYL TECH
a AA 1✓
LICENSED CONTRACTORS DECLARATION QT ELECTRIC PERMIT FEE JOB DESCRIPTION
I hoaby noir...that I a hcamcsl undll,aloisinns of Chs'pmr 9(oleo naming
�pZ whir Sea;ors 9IN101 of Division noire swan'':atm Profa,uam C;Xlmandmy licetoc ix RESIDENTIAL:
PERMIT ISSUANCE
F W 2 in full farce and effect. DWI- OKITCHEN REMODEL
'UE-U I,iansc Class Lic'0 AITLIANC&S-RESIDIfN'IIAL 1 ADDITION ❑PLUMBING FEE PIPE
F z W Da,, Contractor
yQa y PARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUC'1'URAI.
f-D ANELS MOUIPICATION
OZO=G^ IunJenlull my plam'hlp he used uxpnhlic re con]. O0 o_IXIAMI'S
❑INTERIOR C]CI IIMNEY REPAIR
1==t-0 Licensed Platrw onul 2(11-IIXX)AM1IYS IMPROVEMENT OSWIMMINGPCO S
OWNER-NUILDI?R DI!CLARSHON OVERIfxX1AMl'S ❑116CII RIiMODIJJREPAIR ❑DEMOLITION
C Q 1 Mrchy aRmt In.'[;,,I,evmnpl limn the Conauem,',License Law for the
O aU faum.nwing re (Section]031.5,Bu'inessarJ Professions Coda Any cilyo county SIGNS ELECTRICAL OTHER
1+13 LL ti whin''cyano"a puri m a,;;.lm cl.;ller.'mrprav1.dnndish,or repair nay shnnmre
F.LLOQ pnorlo its issuance,alvece ires lheapplicanl forsuch permit It)file a signed.u'mnem SPECIAL CIRCULI/MEC.
�yNjY' that he is heenxed pursuant to lire pmvmians of thCordialLicense law(ChnpmrCordial
R1�00 (emmnencing with Section 70s))If Divl.1ot13ot heHa—c—nal Pnfev,kn'Cade)or 'I HMP.M I?'I Pit OR PO.17 I NST. COMMERCIAL:
a a c C that he i.exempt therefrom and the hasis for the alleged exemption.Any violation of ❑NI?W BLDGIADDH iON ❑UFMOLII'[ON
�^,y Section 7031.5 by any applicant for a emit subjects the applicant n civil penally of POWER DEVICF_S % ❑'I'ENAM' ❑('CUD SERVICE
nnt'nnm bum five hundreddella,Islas)). IMPROVEMENT'
=C Q L,as owner nl lire pmpenY,nr my e'nplo}ces with wages as their wde co'npcnsutlon, SWIMMING POOL ELECTRIC
P- will do the work,and the structure is not intended oraRered for vat,(See.70H.Ratios El OTHER
1W and I'rofcs'iam Colic: File Coult-lo s L Lane Law does nw apply ,,an owner or OUTLEIX-SWI ICHES-FIXTURES
a progeny who builds or improves thereon,and who does such work hinecti or through
bis own employees,IF called that such impnrvemenm art an,intended or offered for NEW RESIDENTIAL EiTCTR SQ hL
laic,11,however.the I Atingar imprvvmucnt is sold wihin oncycurorenmplmion,line SQ.17.FLOOR AREA VSQ.FT
mwofuile.) will have the burden of proving that he did not build or inq,rovc tiro par- 8
pow of eats.).
h ms owner of he See .,,,'n uxulmivad nmf sting with Memel comments i
onzlrvel the pm 't(Sic to an
Rner Ili and py who bei ds orimposes Conaadon, Li
whsc hued lees IapPlyo.anwvne.....I ny I'ca"ms ort ,,te thereon,add QTY. PLUMBING PERMIT 1'F:F.
o cunv;mw fn uhpmjccln whhumnlmemr sl licm'ecd pursunm u'n'v Conrt;¢mr'n '
Liecuse Law. PURMIIISSUANCE
❑ I am exempt Sec. .H&PC for this mason
AI:1' -DRAIN&VENT'-W'AI'IiR(EA VAI,UAIIyyj�N
Own Datc ��� f]/fo �'
WORK'vvE 'S COMI'IiNSAI'LON DIiC1.ARA)are ACK PLOW PROT[CT.DEVICE CCyyJJ{{yy�VO
I hereby at)! under penally 0Inerjury o,,e ofthe lidlowmg Acclnmbons'. l
%Iak
(have and wttill maintain a Ccuifcam of Consenossi6nt im'afurW'orklas ConiNit- INS-1�LUOR.ROOI'.ARIiA.COND. NIORIILSo as provided for by Section 37116 of the labor Codc,for the performance of the
for which Thi.peril is ismed. P T Es-PIiR'IRA[-
L have and will maintain Worker's Compensation Insurance,as required by Section
3700arthe lair Cafe.birdie padbmmuceof the work for which his man is issued, GAS-iv. SITM-I INC.7OUTLFTS OCC.CROUP AYN
My Worket,Conifensutln I Imuran'curler and Policy,,unmet am.
Cancer: policy Na.: S-IiA.S' iH
CLEO[FICXTF OF EXEMPT ION FROM WORKERS' .ASP LWA. '1. 1!PIOR
COIIPENSAI'ION INSURANCE 111 GDIVISION FRES
("Ills wenn,,need not lreeomio
,icha nic perias for re hundred dollars lel W) GR SE
or less, I'LANCIII!CK IT
lied,ydred in lhepc''lienon.alfite—akrarwll'Ich(Ills lemnitls needed,I shell SEWER-SAN Y-,' M1 HAC71101T1,
not employ any person in any manner so as to becomeo the Workers Compen- ENERGY FEE
Z tannin Lawsof California.Dam WATER IWA1'I: 'NEWIE.ICTR
Z A,dream • ' GHADINf.IEii
NOTICE TO APPLICANT':If,after making in,Ccedicam of EemPlion.Yan should WATER SYSTIi / r 'PING
h ;