27621 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO .DINT.-F7'Fi7mricAL PF:RMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL 27621_
BUILDING PRO.IF.ITI'IDEN'rl FICATION
tlUILDIN0 ADDRESS: SANITANY NO. APPLICATION SUB^MITT�AL DATE
2 1' LOT#
O SNAME: PHONE: 'FRA O LIC NO: l �IaV✓I' WWW
I H1 / G N/C CONTROL
RCIIITI.C'I'/IiNGIN1'PR: LIC NO: A ESS:
ONTACt: PHONE: 1 S` '
(� J QTY.i 3i kELE CTRICPLRMIT. FEE - BUILDING PERMIT INFO
53 1J Z PERMIT ISSUANCEG ELECT PLUMB MOH
LICENSED CONTRACTOR DECLARATION APPLIANCES-RESIDENTIAL JOB D. Pf10N
Zwz I hereby affirm that l am licensed under provisions of Chaptm9(commencing with h Y11�
WOO Section70tBof Division 3 of the Busiaessand Profsmiore Code.and my license is in PANELS
FFy-- 'F-. full force and effect.
F<ZW License Class Lic.k UPT0200AMPS
oo<y Date Contractor 201.11100 AMPS
F-"mz ARCHITECT'S DECLARATIONSQ.FF.FLOOR ARCA $/SQ.IT.
ZO'0y G l understand my plans shall be used as public records. OVER I OOO AMPS
G
W SIGNS ELECTRICAL
< d IEansed Prol'c.imanl
W < OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
�d�44 O,U 1 hereby affirm that 1 am exempt from the Convenors License Lew for the
1+134vs following reason.(Sevion 703 Z.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
�,o which r ira5 a permit m construct,also'.improve,demolish,or repair any structure
,'Mai prior to its ismencaril.m requires he applicant for such permit to file a signed statement POWER DEVICES
plcq 00 that he is licensed pursuant to the provisions of the Convenors License Law(Chapter
ff 9(commencing with Section 7000)of Division 3 of Ne Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
,o or that he is exempt therefrom and the basis for the alleged exemption.Any violation of UTLETS-SWITCHES-FIXTURES
tz Section 7031.5 by anyapplimm for.Permit subjects them, penalty of
nut more than five hundred dollars(5500). NEW RESIDENTIAL ELECFR _SQ.FF.
W I,asownerofthe ro n,orm m In eeswithwa esastheirsolecom motion,
o ❑ P pe lu Ye P Y 8 a STORIES TYPE CONSTRUCTION
W, will willdthe work,anile The Conruclumtractors
notinsoicerseaffiensil.do farsale o'apply to an Business
and Professions Code:The ves tremon,License oro,doer sol apply m an owner of
propsuch
ownenywhees,p videdtrovesthereomanments notintwdr orofemdf,sme.I, OCC GROUP RES.UNITS
wnemplayebuilding
uip ing or improvehimprovemenuarenot ear ofdo pletio ,for sale.IL
however,alderwill have
l the or improvement is sold a within oneyran or completion,purmse of T
builder will hove the bathes of proving that he did not buil)or improve for purpose of
ale.).
❑ I,as owncrofthe Property,ameadusively convening with licensal contrecmrsm QTN PI,/BIN PFRMIT FEE FLOOD ZONE MIN
constrict the project(Sec 7(44,Business and Professions Code:)The Convector's
License Law does not apply manownerofproperty whobuildsmimproves th.......nd PERM]'rl ANCE
who convects fnsuch pmjwm with actavnnor(s)licensed pursuanun the Commnors R.DRAIN&VENT-WATER(PA
License Law. FEE SUMMARY
❑ I;un enempl under Sec. B ffi P C for this mason BACK FLOW PROTECT.DEVICE OUTSIDE F:..
SANITARY YN
Owner Date RECEIFIp
WORKMAN COMPENSATION DECLARATION
DRAINS-FLOOR,ROOF.A ,COND. SCHOOLTAX Y N
❑ Ihereby.ffiem shall havenanifimte of ttmsenuoeelGinxure,nrecerti tante ofRECEIPTp
Workers'Campansatinnlnsurance nracer0fird copy Nerenf(Sec.3tl(IU,Lab .)which FIXTURES-PER TR�Nffljs PARK FEE Y
coven all employee's under this permit. GAS.['A.S I .4 OUTLETS RECF.11'I g
Policy p BUILDING DIVISION FEES
Company GAS Et". S iM-OVER4 FEA
❑ Certified copy is hereby hum med. I PLANCHF.CK PCB
❑ Certified copy is filed with the city inspection division. INDUS WASTE ITOR GRADING THE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREA P SOILS FEE
COMPENSATION INSURANCE
(Thissection need not be completed ifthe permit is for one hundred dollars DI SEWFRR SANITARY-STORM EA. FF. LNIeROY FEE
is,less.)
I certify that in the ,f..rSW the work for which this permit is issued,I shall WATER HEATER W/VENTIF.
not amp"
y n in any eo m to became subject m the Workers' PAID
Z Compcn tion Lmm fCnlifo Dg� WATER SYSTEMOR�TING Dine Receipt
Applica D
Q NOTICE LICANT:I.aftcrmaking this Certificate of Exemption,you should NEW RESIDLNI'IAL PLMH. SQ,FF. TOTAL:
F (n becomexubjecno the Worker's Compensation provisiomofthe Lavar Code,youmust
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