21497 APPLICANT TO FILL IN INFORMATIONVITHIN RED LINES— USE BALL POINT PEN ONLY '
Building Project Identification' - PERMIT NO.
Build I,Addreen
� u�ierwc cam . 21497
w ams: . one: - - . .
/ PPIrFi CITY OF CUPERTINO-BUILDING DIVISION•-
Contr4nor'eName: LieNo:•� APPLICATION / PERMIT - - ..�
Architect/Eng3neerl\ ( 4 Lk.Na BUILDING-ELECTRICM PLUMBINGMECHANICAL CATEGORY CONTI�h.YA^/a
i� BUILDING,PERMIT_INFCI r
- Z)TY' i EI,E�'1'RIC HERMIT `AEE 1 • ' ,
Addreas - PERMITISSUANCE Z - ❑
• LICENSED CONTRACTOR'S DECLARATION -
I hereby affirmthat l am licensed under provisions of Chapter 9(commenc. APPLIANCF&RE.SIDENTIAL JOB DFSCRBIION
ingwith Section 7000ofD3vision3oflhe BusinessandPmfeulonsCode,and my -
Li.. lain(uB( and ie.#', j PANE'S
Licence Claes Lie. 40
Dace / oMrado 12 TO 200 AMPS
ARCHITECT'S DECLARATION 101-IMO AMPS
pQ!ZX 'understand my phria ehgll be case pyWcrerordw OVERIOOOAMPS SQ.FT.FLOOR AREA E/SQ.FT.
E od LI marl Profeuioral �� 3 i/ ` SIGNS ELECTRICAL -
Qt OWNER-BUILDER DECLARATION -
Iherebyaffirmthmlamexemptfmmthe Contractor's LicenseLawforthe SPECALCBiCUIT/MISC -
pp iA following reason.(Sectlen 7031.5,Business and Professions Code:Any city or
O z'a TEMP.METER ORIOLE'NST.
�
pcounlywhichrequimsapermittaronatmd,altepimpmve,demolbh,orrepair -
anystmc mpeortoilaiuuancgalsorequimatheappliuntfwsuchpermitw POWER DEVICES
file a signed statement that he is licensed pursuant to the provisions of the
Contractors License Law(Chapter 9(commencing with SeR1on 7000)of Divi-
�0:,1 sion 3 ofthe Business and Profeuloru Code)or that he le exempt therefcmand SWIMMING POOL ELECTRIC - VALUATION
'77 the basis for the alleged exemption. Any violation of Section 7031.5 by any coo ,
Q appBcantforapermitsubjedstheapplkanttoacivilpemityofna =mthan � OUTLETSSWITC XI'UR L W O (6
W five hundred1,asodollars he pm NEW RESIDENTIAL TR SQ.FT. STORIES
G .❑I,as owner of the property, l my employees with wages r thele sole TYPE CONSTRUCTION
compeeation,Boameas t work andthesC dure k not intended or offered for
❑ ole(Sec apply to ainow andfproperty Code:The Contractors Lie Law
does not appiytoanownerofpropertywho builds
ereptl c9,ImpItecithIand OCC,GROUP RES.UNITS
whodcessuchworkhimsel(wthrough hisownemployees,Jurovided that such
improvements are not intended oroffered fwsals.If,however,Ihebuildingw TOTAL:
Improvereentimuldwithinoneyearo(coreplelion,theowner-bullderwillhave ,
lhgkurdenofprovingthat he did not buitdorim rove for u ode of ole.), +^'.4•' •4•`._'., -• `
�LJJ 1,as owner of the P PrP •QTY.';;:i t' '.PLUM- (+".P IT•,'s=4�c� l'`lt'FEE;:;; }7ppD 7ANE APN
Properly,am exclusively contracting with tirensed pFRM] SSUAN E
rontradon to ronstfud the project(Sec.7044,Beigneu and Profeuiotu Code: '
The Contractor's License Law does not apply to an owner of property who ALTER TERRA)
builds or improves thereon,and who rontrads (or such p(ojede with a
cgIlt{adoKs)licensed pursuant to the Contractor's License Law. t.'•„tqt c •FEE,SUMMARYi`.
lJ I am exempt under See. g &P C for this reason BACK W TECT.
• DRAINS ROOF,AREA, SANITARY_ Y N
Owner Date -
RECEIPT N
WORKMAN COMPENSATION DECLARATION FMD( pg PER TRAP SCHOOL TAX Y N
❑I hereby affirm that I have o certificate of consent to self-insure(Sa RECEIPT N
rertificateofWorkers'Comperiution Wunnceorecertltled ropythereof(Sec. GAS EA SYSITM1 INC4OUTL PARK FEE Y N
3800,Lab C.) -
Policy N - - RECEIPT N
Com any GAS EA.BYSTEM-0VER4(EA) - BUILDING DIVISIO E[S
❑pCertoied repy le herebytd. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑CertBled copy V filed withh the the cid.
Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRV', PAID- _ 0
COMPENSATION INSURANCE
OMSEWER-SANITARY-STORMEA 10011. Da ` ' 2 t# roS
ssedian need not becompleted[(the permit la(or om hundred dollars
- WATER HEATER W/VENT/ELECTR ENERGY Y N
'certify hat employ
the person in an ofthe work so as tobeca Berm subject
to ed,the
I shall not empen any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Worlicant ompensaHon laws of California. Date PAID
O Z Applicant - Da R I t#
'Z O NOTICE TOAPPL)ed tot eWorrars'Co paraction pre is Exemption,you NEW RE9DPN'ITAL PLMB. SQ.Ff,
H Code,you
asubject to the Workers'Compeceation previsions of the Labor TOT L:
N- Code,you rrwet(orlhwith comply with such provislons or this permit shall be BI)1 G
- deemed revokd
e .
IL j