20637 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pra'eet Identification PERMIT NO.
Building Addrena:
2163`( 20637
Tywrte s e IW one: A A A
phCITY OF CUPERTINO-BUILDING DIVISION
Contr sora a c o: APPLICATION / PERMIT L v
d — C&#A) 0*A4BUILDING-ELECTRICALPLIMBING- CATECARY CONTROL#
Architect/Engineer. Lic o MECt)AMCAL'
/^c el e.a"'1 QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. g w4
DI Uf U-t• inif" PERMITISSUANCE ❑ ❑ El
CONTRACTOR'S DECLARATION L�4
I hereby affirm that l am Rcensed under provisions of Chapter9(commenc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwlth Section7000)of Division3 ofthe Businessand PrefesslonsCode,and my
I'loofinco.in full fprAe and died. / 22� rpNEls ,
Date seCkss Lk.#
Date Contractor
ARCHITECTS DECLARATION 201-1000 AMPS
q�++D CO e useaspucrecords.]understand myplamshaUbd blOVERI000AMPS SQ.FT.FLOOR AREA
FZr I] LlmnsNPrfesslovl SIGNSELECTRICAL
Q OWNER-BUILDER DECLARATION SPECIALCTRCUIT/M R r; r
IherebafArm that lam exempt
from the Contractor's License law for the
- 7a Y
O F,x foflowingreamn.ires,aprmittoosinemandr,Imprve, ernol Myctepir TEMP4POWE�DEVICES
ETERORPOLEINST.
��pp uu33 countywhkh requlresa perMttororetmct,ilter,impmve,demolbh,or, repair
anystmu mprlortoitsbsuance,aL quireatheappliontfwwchpemtitto file a signed statement that he is licensed pursuant to the provisions of the
Contractor's Lerme Law(Chapter9(commencing with Section 7000)of Divi- OL ELECTRIC
sion3 of the BusinessandPrefeast..CodOmthat he is exempt therefrom and _ VALUATIONapthe barbforthealleged exemption. Anyt tolacon ofSection not mreany - � OtC ape hundreddolt for. ars(SS ecu the applicant toatlWl perulty of not more thanflue hundred dotbrs(5500). a
IIALELECTR
7�n ❑Las owner of the property,or my employees with wage as there sole STORIES 7YI'E CON5IRIICTION
mpons< cols Ckc. 0KBuleo the ess and Pr and the adurebnMIntended o License
d for
Law
5 O sale ldoes nec. pply toartlOwand Professions,Code:The Contractors License law
g$ whodossuch loan owner of through lds
and C.GROUP RFS.UNITS
whodoessuchwork himself orthroughhisowne.If,li weprovided that nor
Improvementsarenm Intended arofc foraale.ILhower- the buildingve TOTAL:
improvement bsold withinoncycaro(complelion,theowner-builderwlll have
t4LIZurden of proving that he did not build or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOG ZONNE APN
L as owner of the properly,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(See.7014,Business and Professions Code:
The Contractors License Law does nu apply to an owner of property who
buALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereoM and who contracts such p(ojects with a
co.,Iactor(s)Rmnsed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ 1 am exempt under Sec. B&P C for this reason
Owner Date DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N_
r� WORKMAN COMPENSATION DECLARATION RECEIPT
m
❑I hereby af(imn that 1 have a niRcate of consent to scINnsure,m a FIXTURES-PER TRAP SCHOOL TAX Y N
certi(Imte of Workers'Compersatlon Insurance or a certifledcopy thereof(Seo RECEIPT#
3800,Lab C.) GAS EA.SYSTEM-I INC.7 OUTLETS PARK FEE Y N
I'ollry x RECD p
Com an Winedcopy b famished. GAS EA.SYSTEM-OVER 4(EA) BUILDING
DIVISIONFEES
certlBea ropy b filedwith the city Inspection division. GRFASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFIC