99120117 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY 2 O
CITY OF CUPERTINO BUILDING-ELECTRICAL °-
CAL
BUILDING DIVISION APPLICATION/PERMIT PING PROJECT
IDENTIFICATION ItU11.DINC PN(gltC'f IURNTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUUMII"I'AI.UA'I'fi
2m3 z� C'
OWNER'rS NAME: 1'HON1i: CON'FRAC'IO ;,S MI?: LIC NO:
KJ kg �5#At2.5 2�3 leZ(C'� �$ �" � CO N/C CONTROL#
RCHITECT/F.NGINEER: LIC NG: ADDRESS: ❑
64,0 Avg S�rvyu
In ONTACD PHONE. BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. 'ELECTRIC PBRMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing _ JOB DESCRIPTION
"Z ....Satin.71N1(fl of Division3of the Rusinns and Profession,.Code,uL:
nd my license is RESIDENTIAL
W O p PERMIT ISSUANCE
� in full fereeand effect. El ❑KITCHEN REMODEL.
FW
RLicense Class Lie.
1U TI
APPLIANCES []ADDITION ADDITION PLUMBING RE-PIPE
�<� Date Contract...
>y ARCHITECTS DECLARATION PANELS El MULTI-UNIT El STRUCTURAL
~inz l understand my plans shall be used a.public records MODIFICATION
z0y:o UPTO200AMPS ❑INTERIOR El CHIMNEY REPAIR
L.�t:al Licensed Professional 201-10(MAMPS IMPROVEMENT (]SWIMMING POOLS
r.1'f j OWNER-BU1LDIiN DECLARATION OVER 1000AMPS El BATH RPyJ r �EC� EMOLI'I'
C Q 1 hereby affirm Nos 1 am exempt from the Contractors License Law for the
X 6 U fallowing reason.(Section 7031.5.Business and i'rdesclons Code:Any city or county SIGNS ELECTRICAL ❑OTHER 3�T
W 3 LL N which requires a permit m construe',after,salmon.demolish,or Repair any evumure
�.''on, PH.".asismance,also requires the applicant forsuch permit o file a signed statement SPHCIALCINCUI'VMISC.
S#�hy that heislicensW pursuanuothe pmvisinns nfthe C.nweors license latw lCTapter4
a.�Qz that he
ingwabheefroman7of Divisionr ophe Businesscad Pro Any violation
)or TIiMI'.MISTER OR WLH INST COMMERCIAL:
a a c tL @m he is exempt therefrom and the basis for the subjects
exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
'y Section 7B3LSve any hundred dolfor a lars
xuM1juss the upptitum mucivil Penalty of POWER DEVICES ❑TENANT El FOOD SERVICE
t more than five hundred toilers(SSW).
I-ZY ^^ IMPROVEMENT
=QI]Lashe work.the property,or myetintened withered for sale
asmpcnsiness SWIh1MINGNXiLE1.liCTRIC
EFC will do the work. dthcnmCurt istors Licenseded Law
of apply it)
[rosiness ❑OTHER
to and Professions ild,Code:The Contmctoh License Law JRcs w apply es if owner.f OUTLITS-SWI'I CITES-FI%TU
6 3� property who boil).or improves IM1erton,and who Joey such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL.ELECTS SQ
sale.If.however,the building or improvement issotd witbin one year of completion,the
tuimprove
FLOOR AREA S/SQ.FC
ner-builder will have the burden of proving that he did not build or imro
pve for put.
pax of sale.). 0
TOTAL"
❑l,cnwneref she property,am exclusively contractingwith licensed contractors to
construct he project(Sm.70414,Business and Professions C.J1:)TIM Cotenants Li-
mine Law does not apply to an owner(if
i-mineLawdoesnotapplytoanownerof property who builds or improves thrnnn,and QTY,' PLUMBING PERMIT DEC
who contracts for such projects with a comtracmpursuant gs)licensed pursuano the Contractor's 1 1999
License Law. PF.RMI"f ISSUANCE
I ant exempt under Sec. B&1'C for this onus..
ALTER-GRAIN&VEM'-WATER(EA) DY VAIAATION
Owner Dam D
WORKER'S COMPENSATION DECLARATION BACK FLOW PR(H'ECT.UIiVICF.
1 hereby affirm under Penalty of perjury ental she inllowingsure(or declensions:Conifer-
Ihave and will main mina Certificate of theConsent to
Laor Code,for the Worker's of he DRAINS-Iq.00R,ROOFAREA,COND.
tion,as provided for by Section 3700 of the Labor CnJq Int the perfommnce of the STORIES TYPE CONSTRUCTION
work for which this permit is timed, FIXTURES-PER TRAP
7have and will maintain Worker's Compensation insurance,its required by Section
14 y nfthe Lahr Cede,for the performanueofdhe work ter which this permit is issued, GAS-EA.SYSTEM-1 INC.4 OU'I'LI?TS OCC.GROUP /1 rp
Mor er' emmi n lnsumnce carrier unA Polk 7
We x"�STJ GAS-EA,SYSTEM OVER 4(EA)
Cartier: ` Policy Nn:n w`
CERTIFICATE OF 1?