S 2334APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO RU I I.IIING - RLEM RICAL PERMIT NO.
dIIII,DING DIVISION AI'I'LICATION/PF,F[A7IT ^,,,, PLUMBING MECHANICAL^!!.T ,v 1; A ^f A
CONEACT:
LICPNSHD CONTRACTOR S DECLARATION
I hereby ullimi Ihe, I mu hai,owd underpim sion mf Chapter 9 (mmmcrc'mg
with Soman 700)(0af hoisim3.l tk Businn.amlPmesswor dc, aM mylicet,e is
v
QF,ur LoculieCI.,ld cRsrl.
UU [)aid tau Lic.Y
6 Doe Cunlelor
ARCHARCHITECTSUECIDECLARATION
pn Z I umkrsmd my plans shall he used as public rsvrds
Z-lz
,'9, R W Liccnecd i'mf sirmul
OWNER- BUILDER DECLARATION
C C Q I hcrehy affirm that I am escmma
pt from the Ontmr, .w 's LicenImw For me
3 a U following transact. (Section 7031,5. Business oml Professions Code: Any city oT county
=O<which rermres s prnail to coagw, idt , improve, demolish, or o au any s,mcmrc
J Prior to ifs issunce. dor requires m, applicant for ouch permit to rile a signed swemrm
too beisbernsN punuam mthe pmviawls M, he Com ream's Lic ,LawlChegcr1)
DO (cornori with rection 7 )bo N Di vision 3he Business a ml Rofessmmne Code)or
p ry that IN its escmle tMmlmm wd Ow Muis for the.11,crl eseral Any violas- of
W y See, n70313 by any aPPINant for a Permit subject, the" inns ma civil pemlty of
nor wort than five hurdrr l &Alan ($50(1.
� C CI 1.4. owner of the prdmperty.or my employees with waspssClair, rale sonmpcmwidm,
will &m the wreck, aM the Armcwrt n ter onerMsd m oRrnd fur ole ISce, 7(10, Business
C 3 and ITorrssim, Code:'Poe Contrumis Iysme law doe+ ret apply to an mvr,er of
Porcny who Wilds m imlx.vcs thereon, wd who does such work himself or though
his own enor.,ews. pnwidkd that such impruvemenu art nu ire, d dr offered for
talk. If, h.wnaJhe building or imlamsemsme is suM within me year of eumple ion, the
or,sner-1,uild, will hoe the burden of Driving tlwt he dM no, haild or ImPmve for put-
ofal
Fs
us owner of IIs: po)P ry, um eaelusively cnnv lion wire IiLcrs cstmcnm to
.adact tk Project (See, 7(l i BminNs. aM Profession, Code:) The Cormicies s U
eco. I,w joe, ma up Ply In an owner of popery, No hui Msdu impnrvws manta. oml
is ho contracts be, such Pojren wire a pw,memr(s) licensed purstwtt to the Commom's
j".. Law.
O 1 am rsOmP Ilqkr Sce. . B R P C fa tris —no
PC1ZT(hr0 q
So 1 L4
SEISMIC FEE
ELECTRIC FEE
'ON 'I'RACUTR'S NAME:
LICNO:
NIC
❑
a
CONTROL
,DDRESS:
❑ Cons.1tnnt Fecs Paid by Applicant (Initial)
d U ILDING PERMIT INFO
RLIK ELECT
❑ ❑
PLUMB MI CIA
❑
)TY ELECTRIC PERMIT
FEE
JOB DESCRIPTION
RESIDENTIAI;
❑SIUWL ❑ KITCHEN REMODEL
❑AUDITION ❑ PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIMCAIION
C1 INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT ❑SWIMMING PMIS
❑ BATH RI?MODF,I JRF.PAIR ❑DEMOIPON
❑OTHER
PERMITISSUANCE
APPLIANCES-RF'_SIDEN'FIAL
PANELS
UPTO 2(lB AMRS
20I-INX)AMP5
OVER IT00AMPS
SIGNS ELECTRICAI.
SPECIAL, CIRCUITIMISC.
TEMP. MGI'F,R OR POLE INST.
COMMF,RCIAL:
❑ NEW BLDG/ADDH ION
❑TENANT
IMPROVEMl7T
❑ OTHER
❑ DEMOLITION
❑ FOOD SERVICE
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - S W ITCI IIS - FIXTURES
NEW RESIDENTIAL ELECTR
SQ FI'.
TOTAL.:
SO 17. FLOOR AREA
SISQ. FT
-----W!)RKI?R'S COMPENSATION DECIARAUON
1 hereby onion umkr placidly of perjury ore of the following dcchvalnmM:
cin. ,endwlet! for
Seelum 37M of ConumumCorensurc epit,4kcd eath-
.,,Af as hell mi fur by is icord.
]700 of IM lab« Crede, for the pMdmmutee M the
wswk forwhbh ill arms is orlart
1 haves I.a will normo NM1m&cr'a Camprn.wtion Irk Ter which
h isPer by S suAl,
myor
ofrhohalm Core. tor the Ieran,c cana:urine wadf uwhich Inie (_nail in inwurl.
Myier: Cotnpemutm Inwarcc mrricrowly No.: number
Carrier: I'olioy No.:
CHKfIPIC O OF SATE NINSFROM WORKERS'
COMPENSATION INSURANCE
forlEhls.ucuun r,OOU not he mmpMN it panus is Rx rents huaYnl JdAlnrs (SI WI
or lou.)
I crib y tform die pMdnnartce nl the work ler uhoeh this prom is uwedL I eha11
ret employ any peon m any manna m as Ire become whjem m Ihm Workmi Como
O z Winn laws,( Cahtom,m. 1).
Applicant
NOT CH TO APPLICANT: It. after staking this Certificate of EsemPnmt, you Imuld
a > become subjm to the Workers Compensation pmvon
i -of the Lehr Code, yore must
hmhwim comply with met Pros,nmas or for Pcmul shall be dented resoled.
0.0
CONS] RUM JON LENDING AGENCY
V Q (hereby my. mat there iso mrtunuct. kmdingage y for Perfocmanceof
I--� IM work furwhich,his term, is-url(Sae. Y097. Civ. C)
0 C.7 Leral Name
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