21984 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 21984
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are: ane:
,p v CITY OF CUPERTINO BUILDING DIVISION
°"tw cur'."•^•, Lic.No: APPLICATION 1 PERMIT i
Archlteci/Engineer.
BUILDING ELECTMCAL-PLUMBINGMECHAMCAL CATEGORY CONTROL s
Llc.No:
QTY ELECTRIC PERMIT FEE BUILDING P IT INFO
Address: POWTISSUANCE .Q i ❑ ❑ ❑
Len that Is CONTRACTOR'Sunderprovisions
I hereby ivacrsedhcB.k ro..nd sof Chapter9de,and o APPLIANCESRESTDENIIAL TOB DESCRIPTION
IngwehSection force of d died.3 oftheBukneaeand ProfesslonsCade,and my
Ltmre k in full force and effect. PANELS C�jf
Llrnnx Ckse LICK
Date Contractor
ARCHITECPS DECLARATION 201-1000 AMPS
9777 I understand my plarushall be used as publleremed . OVER1000AMI$ SQ.FT.FLOOR AREA $/SQ.FT.
Ob
u Licensed Pm(evi°vl SIGNS ELECTRICAL
Ihcnby.M�6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
0F owbigr sson that l am exempt from the Contrador's License Law for the
p following reactors.(Section 7031.5,Business and Pmfesslons Code:An ci or
2 � y ty TEMP.METER OR POLE INST.
anyMmenue requiress permit torn kmR,altenlmprovgt forsuch,arespair mitto
[� .ray kmcted st to seta that
he i,ak0 sed pursuantscuinnithe t the provisions
of permitto POWER DEVICES
Q 6� file-signed katement that he k licensed pursuant to the proWlona of the '
3 w0 Contractor's License Law(Chapter 9(mmmmuleg with Section 7000)of Divi- SW'I NE NG POOL ELECTRIC
(., elon3of the Bualneasand Profesekm Code)orthat hekexemptthere(romand ATION
$ the basis for the alleged exemption. Any violation of Section 70315 by any 9 aj�GD
OUTLETSSW[TCHFSF(XTVRES
applicant for a permit subjects theappuc t too civil penalty of not more t Kan )
w five hundred doll..($.500). NEWRESIDP.NIIALELECIR SQ.FT. TYPE CONSTRUCTION'
7¢ ❑I,as owner of the property,or my employees with wages es their sok
Cmep¢nsatlon,wlll clothe work and thestructure is not Intended or offend for
❑
-Is(Sec.70K Businessami Professions Code:The Contractors License Law
docs not apply to an owner of property who Wilds or improves thereon,and OUIP RIS.[1NIT5
whodoessuchworkhimself orthexigh Nsownemployees,provided that such
improvements are not intended oraffered for ale.1(howevepthebulldingor TOTAL. -
improvement ismld wLLhin one yearfcomplellon,the owner-W Bderwill have
t1�,�len of proving that he did not Wild or Improve for purpose of ale.). QTY. PLUMBING PERMIT FEE
I�QL as owner of the property,am exclusively contradict,with llansed FLOOD IDNE APN
PERMITISSUANCE
centexcton to mmtmet the priod(Sm 7044,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER
-DRAIN re
builds or improves thereon, and who contracts for such p -
tojechs with a DRAIN&VENT-WATER(&D
�gp�aetor(s)licensed pursuant tojlye Contractor.LI...Law. FEE SUMMARY
Lf I am exempt under See./ B&P C far this revon BACKFLOW PROTECT.DEVICE
Owner -47 Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
• WORO INSATIO DECLARATION RICEI'IX
KM
❑I hereby affirm that I has.a artlBaa of consent to self-insure,or a JUTURES PER TRAP SCHOOL TAX Y N
mnifiateofWorkers'Compematlnnirm mnmoraarti(Wmpythemof6ec. RFC M
31100,Lsb C3 GAS EA.SYSFEM.I INCAOUTLEfS PARK FEE Y_ N_
Pollry N GAS P.A.SYSTEM-0VER 4(EA) RECEITT If
Co������mppppppany BUILDING DIVISION FEES
"Vis
copy k heed with the
city CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
L�Ji Certified copy k tlkd with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE'TRAP PAID
COMPENSATION INSURANCESEWER-SANITARYSTORM EA 200FT Date RCtt'1 IN
(This section need not be completed If the permit Is forone hundred dollars P
u100jcefWATER HEATER W/VPNT/ELECTR ENERGYFEE Y N—
I
ceHfy that In the performance of the soak for this permit is issued,1 shall not employ any person in any manneris,as to bernme subject to the WATER SYSTEM/,TREATING
Workers'Compenaation Laws of C.Ufomia.Data PAID
Z Z Appllant NEW RESIDENTIAL PCMB._SQFI'. Date Remi 111
Z O NOTICETO APPLICANT.If,after making this Certificate of Exemption,you
should berme subject to the W°rkeri Compe...it.previslaru of the Labor TOTAL:
laN Code,you mu at forthwith comply with such provisions°,this permit shall be BUILDING
j