21982 (2) APPLICANT TO FILL IN INFORMATION WITHIN REDLINES — USE BALL POINT PEN ONLY
Buildln Pro'et ideml(k ti.. - PERMIT NO.•
Building Addrev: - - G I f��I a9Jn(� n
8G
. w1 •^aA'. ^ p/ CITY OF CUPERTINO-BUILDING DIVISION
JW
cono-tnr Na : A L=.NOn/ APPLICATION / PERMIT
BUILDING-ELECTRICAL PLUMBING-MECII LAICAL CATEGORY - CONTROL M
'Architect/Engineer. Lk.No:
'Qti"y� t ELECTRICP,ERMIT'I t • � hr' FEE', ), '�'. 1'.+BUIL DING PERMIT,INFO
Address: ' PFRMITISSUANCE a ❑ L1r �C
LICENSED CONTRACTOR'S DECLARATION Yom'
IMrebyafflr70 that lam lientsed oftheunder pessand sof ChionsCo e,and c APPLIANCESRESIDENTIAL ]OB DESCRIPTION
Ingwlt Cjn1on7000)of diiWect. olthe Buslxmandl'rofeaslonsCode,and my - y
banxmtn cul secret. � PANELS
Llanx Cl ae Lie.a1�
Date Contactor �I AIr —UP IQ 2DO AMPS
ARCHITECI•SD CLARAi rd W OVE 000 A.4f[5
Q p70p, I underemnd my pisco shall be used a public records. OVER 1000 AMf5 SQ.FI'.FLOOR AREA 5/SQ.FT. '
(/ Licensed Profeasional - SIGNSELECTRICAL
6 w OWNER-BUILDER DECLARATION
G.]Fd SPECIALCItCU1T/MLSC
Z F''4r. Ihereby a(Ormthat lamexempt LDER the LARAtntBLirense Law(orthe
following reawn.l5etlon 7Qi15,Business and Prolesslona Code:My tty or
FE' countywhtchrequlmapermitmcorutvn,alter,impmve,demol6h,orrepair TSP MEfERORI'OLE INST.
anystrunurs priorto its issuance,also requlresthe applicant for such permit to
6 O I file a signed statement that he is licensed pursuant to the provisions or the 1KIWER DEVICES "
Q63µ Contractors License Law(Chapmr9(commentlng with Section 70X))of Dlvi- SWIMMING POOL ELECTRIC
FEtO< eion3.fthe Businemand Profemi.o Coae).rlh.1helsexmp"hemfmmand -
VALUATION
•.1 the basis for the alleged exemption. Any violation of Senlon 76115 by any
6X
applicant for a permit subjects the applicant to a civil penalty of nor mom than OUTLETSSWITCFlESF1XNRES.
live hundred dollars($W.
pm NEW RESIDENTIAL ELECTR SQPr. STORIES- TYPE CONSTRUCTION
�, ❑I,as owner of the property,or my employees with wage as thele offered for and
compensation,will do theBeaux..and
k.desslo atmdure6mtltracto'ntended o License
Law
M vie(Sec.apply
to show owner
fpmpeAy Co buildsThe Contractor.Lireroe Law
S docs ns,apply torn owner ofproperty who nlidsorimprovesthereonand OCC.GROUP RFS.UNITS ,
who does
mentsa not
ntended hmughhis ownemployees,providedthatsuch
improvements ithindneyear (comered orvk.If, theWilding or have - TOTAL:
Improvement 6sold within oneyearat Wild or Improve
the a for purpose
r Ione of sl have -
t1LjI,dartof wner of theng t he property,am
exclusively
xcl orimpmveracing wieordkJ. QTy„� , PLUMBINGPERMIT '^FEES” FLOOD ZONE APN
Ll L as owner of the property,em evcluei Business
ess and Ing with sCode: -
contnctors to mtuwt the project(See 761y Buainen end Prolevlaru Code: PERMIT ISSUANCE
The Contrenore License Law does net apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA)
Wilds or improves thereon,and who contracts for such projects with a -
c ator(s)licensed pursuant to the Contractor's Llconse Law. a'���:•'�;:,' iii FEE,SUMMARYq,�•t'••'• •�•
LJ I am exempt under Sec. B k P C for this reason BACK FLOW PROTECT.DEVICE OUTSH
P FEE 5
DRAINS FLOOR A,ROOF,ARECOND. SANITARY Y N
Owner - Date - RECEIPT 0
WORKMANCOMPENSATIONDFCLARATION FIXTURES.PER TRAP SCI COOL TAX Y N
b[II hereby affirm that I have a aminate of consent to self4esure,ora RECEIPT
N
XtL teofWorem Compensationlmuranaoramrtllledcupythercof6ec. CAS EA.SYSIIId-]INC.40171LEI5 PARK FEE Y T
3800,[#-CJ (VJ rT�Iy(�-
Poll p Y A. /o — - RIiCEI'1''
Policy 1 CAS EA.SYSTEMAVER d
Co y '], r Qni (EA) "BUILDING DIVISION FEES
i'n _':etlfle copy-Is he d with n ea. GREASE/INDUSML WASTE INTERCEPTOR PLANCHECK PGE
if
Cectlfletl copy ls Rled with the city Inspection diviNon.
���� CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE faW SAMTARYSfORM EA.]00FT .Date Reel t#
(TNseenlan need net W complaed[(the permit ls(atone hundred dollars
(5100)orlev.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
]artily that In any pehe rson
in anye of moanerhe so as towhich camhis ermlt 6 iso theed, I - '
I shall not employ any person In any manner w v m-ammo subject to the
worker;Compensation Lawn nr California.lifornia. WATER SYSTEM/TREATING. Date PAID- '.
O Z' Applicant NEW RESIDENTIAL PLMB. �.FT. Date Rectal t#
Z 0 NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
Fsu
should become bject to the Workers'Camru
peatlon Provisions of the Labor TOTAL:
j