31027 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO - BUILDING-Itt.EC9'RICAL PERMIT NO. ��O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDEA PIF'ICAI'ION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
I a 8-L4, S
OWNE 'S AME: - PHONE: CONTRACf R'SN E: LIC NO:
w - NIC
CONTROLa
ARCHHhulIENGINHII: LIC NO: ADDRIS.. ❑
coNTacr: Prowl: BUILDING PERMIT INFO
Consultant Fees Paid By Applicant(Initial) BLDG El.li PLUMB MF,CU
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby alTiml that l um licensed under nd Pro.ns i Chapter rl(crmmense us JOB DESCRIPTION
OV'Z whh Section 7tllN1)nf DivisinnJof the Broin ss and Profexsions GMe,tmdmyliccnsein
�DO PEERMIT ISSUANCE RESIDENTIAL:
W, iaceme Zcond,flea. �� SSS
�VU�FJ Lsense Class Lid.g ❑SPDWI. ❑KITCHEN REMODEL
F�W Dam Commdor AITLIANCIS—RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
I,- ARCHITECTS DECLAIOUN N PANELS ❑MULTI-UNIT ❑STRUCTURAL.
a
Z 0y 4 1 understand my laps shall be used as public remN.s MODIFICATION
OZ�C 11PT02fX1AMPS ❑INTERIOR ❑CHIMNEY REPAIR
1.�FW Licensed Prnfesional 2111-It](XIAMPS IMPROVEMENT
,4s y7[4j OWNER-BUILDER DIiCLABncial OVER 1000 AMPS ❑BATH REMODEIIREPAIR [I DEMOLITION
C[{W Q 1 hereby,(Sero on 1 um exempt from the Canons Co License Law for the
ip5,O L U following reason.(Seaton 71BI5, t.older. and Professions Cade:Any city or county SIGNS IihIECTRICAh ❑OTHBR
W 0 F which requires n permit re couttue,ulcer,improve,demolish, file
repair any swment
thin
hi rto heisfi.clnce,alomitin reeeapplicanl 6usuch Contractor License ned aw(Ch,mem SPECIAL CIRCUIT/MISC.
thatheisliod,wiit PSectio 7000),f Division
of theeBledreocLicense Loons Code)
apter 9
p0 (commencing with Section 7lNNl)of Divisi.n 3o1 the Business and professions Code) TEMP.METER OR POLF.INST. COMMERCIAL:
d K n IL that he is exempt therefrom and the basis for the alleged exemption,Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 byumyapplicum fora permit subjects the applicant to a civil Penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
n more than five hundred dollars(S51Np..
t?C 0I,uowner.f the prnpeny,or my employees with wagesns theirzol<c.mpensa0.n, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the dical is not intended confined for sale(Sec.7044,Business ❑OTHER
and Pmfessions Code:That C.mmcmr's License law dues antapply to no owner of OUTLETS—SWITCHES—FIXTURES
a a.. property who builds or improves thereon,and who does such work himself or through
his own employees,Provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECIR SQ PT.
aide.If,however,the building or improvement is sold within one year of completion,the SO_f:T.FEOftPEA USQ.FT.
u-builder will havethe burden of pr.vldg thin he didnm builder improve for par" �7 �\ Q.� -
prseofsale.).
1,as owner of the property.um exclusively contracting with licensed contractors to /�p
oswa the project(Sec 7044,Business odd Professions Code:)The Contractors Li- - 6 RECD
Li-
term Law does not apply loon owner of pmpeny who builds.,improes vthence and QTY, PLUMBING PERMIT FEE MAR
who contracts fnrsuchpmjects withatonracmKs)lice®edpursuaduothe Contractors CI1Y License L.W. y
Y Ur t,UrtH I INC)
❑Lae exempt under Sec. ,H&I'Cfor this reason PERMIT ISSUANCE
Owner Dam ALTER—DRAIN @ VENT—WATER(IEA) VALUATION
WORKER'S COMPENSATION DECLA RADON RACK FLOW PRO'T'ECT.DI3VICF,
1 hereby affirm under penalty of perjury mneof the following declarations:
❑I have and will maintain affertifcate of Consent o self-insure for Workers Compete DRAINS—FLOON,NOOF,AREA.COND. STORIES TYPE CONSTRUCTION
smite,as provided fnr by Section 3700 of the Labor Code,for the Perfnmunce of rhe
work for which this permin is issued. FIXTURES—PER TRAP
❑1 have anal will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Codd,for the performance of the work for which this permit is issued. GAS—EA.SYSTEM.I INC.4 OUTLM OCC.GROUP APN
My Workers C=41on Insurance carJ Policy num¢r ar
Cartier: Policy No:' I, GAS—EA.SYSTEM-OVER 4(EA)
1 L PTION FROM WORK.NS'
COMPENSATION INSURANCE GREASFIINDUSTRI.WASTE INTERCEPI'Ok
(This section need not be completed if the permit is lbrome hundred dollars($100) BUILDING DIVISION PILES
or less.) GREASETRAP
PLANCHECK FEE
Loy an,thm in in..,ounce, o us no hrkrrewhijM1 this the Workers
C...per- SEWER—SANITARY—STORM EA.200 FT.
not employ nay Person in any manner sr,as to tnnrme subject m the Workers'Compel- 'ENERGY FEB
Z
sation laws of California.Date
z Applicant WATER 11LATER WNENT/ELF.CTR GRADING FEE
V1
NOTICE'10 APPLICANT':II;after musing this Certificate of Exemption,you.should WAI EN SYSTEM/fREAI'ING
a ;