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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATIONMERMIT PLUMBING -MECHANICAL
BUILDING PROJECT' IDRNI'H ICATION
PERMIT NO.
Q - (i ^ �O
J G !-�
BUILDING ADDRESS Co 1 O � � ,' � �� � �
[//
SANITARY NO.
APPLICATION $UBMITTAI. DATE
_
/� vifoNE:
OWNME:
Q % E(, 1
CONT,RA(CTOR'S N/AME: LIC NO:
Cl'us'{(1.1(1%p+1i (ate j
NIC
❑
CONlRO1.M
' ARCHITECT/ENGINEER: LIC O:
ADDRESS
6Y 610 ,J�or�1 wT4.
CONTACT PHONE:
BUILDING PERMIT INFO
2— ^ /
7 Z5
❑ Consultant Fees Paid by Applicant (Initial)
BO ELLE PLUMB MIC 1
A
LICENSED CONTRACTOR'S DECLARATION
1 hereby abandon 1 um licensed under provisions of Chapter 9 (commencing
Q7Y ELECTRIC PERMIT FEE
JOA DESCRIPTION
PIiRMIT ISSUANCE
with Section 701(1) of Division 3 of the Business and Professiore Code, and my license is
m full force and e0 eat. M L, (
RESIDENTIAL'
QSFDWI. [I KITCHEN REMODEL
APPLIANCES - BESIDENTIAI,
] V43
Licit Carr ]
Da¢ Cemactor
❑AUDITION �PLDMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
[I INTERIOR C3 CHIMNEY REPAIR
IMPROVEMENT E]SWIMMING POOLS
{ ARCHITECTDECLARATION
1 understand my plum shall be used as public mounds
PANELS
UP T02fIfIAMPS
j Licensed Professional
201-IOWAMPS
i I OWNER -BUILDER DECLARA'T'ION
1 hmaso .(Tens on 1 am exempt from the Cessions o License Law for the
following reason. (Section ]1131.5, nosiness,atr,and are, de Professions Code: Any city nr county
which require, a permit in construct, alter, improve, an repair any structure
❑BATH REMODEIJREPAIR El DEMOLITION
❑OTHER
S rN 2 - urN AN«
OVER Ime AMPS
SIGNS ELI?fTRICAI.
SPIiC1ALCIRCUIT/MISC.
h peadit t
he hovisios o for mcnpermr's Lienar, La (Chaps em
patlieiliensed pursuant to vlam Olins eenuacan'a Law
that lieispnavent m the
COMMERCIAL:
Prxe
ofUs and s Code) or
ro .,it In basison30fuloged orss anJma An si ligin. or
that he is ingwi0thereSection
, hm he is exempt therefrom wJ the noesis fnr the alleged exemption. Any violmion of
Section 703 as by any applicant for a permit subjects the applicant to v civil penalty of
t more than five hundred dollars ($500),
01, as owner of the progeny. or my employees with wages as their sole compensation,
will Jo the wank, ant the suamure w not intended oe offered for sale (See.7044. Business
i and Professions Cade: The Contactors Lima. Law doe, not apply to an owner of
'TEMI'.MRER OR 1'OLF.INST
❑NEW BLDG/ADDITION [I DEMOLITION
TENANT ❑ FOOD SERVICE
IMPROVEMENT
0TH'
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTIJsfS - SWI ICHM- FIXTURES
' progeny who build, or improve, hereon, and no dee+.sod, work hm,df or lhron th
his awn omldo,rta, provided that such improvements arc not intended n of erred ter
sale. if, however, the building or improvement is sold within one year olcompletinn,the
NEW RESIDENTIAL ELECT'R SQ Ff.
SQ. FT. F1IX)R ARfiA
S/SQ. t1'.
ownenbuiWer will have the burden of proving that he did not nulla an improve fnr pur-
'TOTAL:
pose of plc.).
I, as owner of the progeny, am exclusively conuucting with I cenmd smanwmrs m
QTY. PLUMBING PERMITFEE
tmomet the project (Sec. 7000. raeuress vad Prefeador Calc:) The Gtmarmr s Li -
crow Law does not apply to an owner of property who had Ids or i mpowes thereon, and
who contacts Onsuch projects with v eantmemr(s) licensed pursuantEn the Comrucmr'x
License Law.
❑ lam exempt under Sec. ,B& P C for this rwsan
l PERMIT ISSUANCE
ALTER - GRAIN & VIOTT - WATER LEA)
VALUA9'[ON
Owner UIO
WORKER'S COMPENSATION DECLARATION
HACK 11000 PROTECT. DEVICE
'
under genahyol permTTON
thafollow for talker's
STORIES
'IYI'R CONSTRUCf10N
ofConeneof Cs:
maimid
❑Inane and will of nsurm
have
Wrfornisceop
URAINS- FLOOR. ROOT',AREA. COND.
the
3700 of the LUMr Cola far the perfnmtonca of the
panaidl for byneCion 3700 The Labor Code.forthe
is...k as hick thi for by is issued.
wed fur which his permit is issued.
EI%TURES -PLR TRAP
1 have and will nraimain Worker's Compensation hicumnee, as required by Section
37 olthel.atmr Cm1,.1 r the tvrformerwrofshe week for which this permit is issued.
My c Worlo,' Cyntpegs nflLiur ce cyP' J Policy 9�ry�r�pJ �B� �B
Carrier: Ss'fAY �Policy Na:
GAS - EA. SYSTEM -I INC. J OEM LCIS
OCCGROUF APN
GAS -IiA. SYSTEM -OVER 4 ETA)
GREASEENDUSTRL WASTE INTERCEPTOR
TL-llz
CERI'IPICAI'13 GF EXEMPT ION FROM WORKI?