21516 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pra'ect Idemificad.n - PERMIT NO.
Building Address: 21516
wrsrsone: A A
( 7�_(� PAO1 I Irt '[, CITY OF CUPERTINO-BUILDING DIVISION _ I -j—
APPLICATION I PERMIT
BUILDINC ELECTTUCA MUMBINGMLCHAMCAL CATEGORY CONTROL N
Architect/Englceer. Lk.N.
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address PFRhtITISSUANCE ❑ ftp ❑ ❑
LICENSED CONTRACTOR'S DECLARATION of ChON JOB
Ihereby thSrdkm oo that I am70]eofDiv licensed ofthe usinesand Pro Chaptea9(e,and m- APPLIANCE"+RESRJEN'IIAL JOB DESCRIPTION
inenseiSection force Af Dlvimon3 ofthe Buslwssand Pro(esmoaCodc,and my
Licaree e,In(u0 form surf d(ed. PANELS
License Chs LION
Data Contractor UP TO 200 AM
ARCHITECTS DECLARATION 211-IODDAMIS
q�q�uu aO zzC I understand my plaa.ball be used as public remade. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.Ft.
E (0 Licensed Professioal SIGNS ELECTRICAL
< OWNER-BUILDER DECLARATION SPECIAL CBiCUIT/MISC
I z 1 herebyafflrmthatl amexempt from the Contradorb License Law forthe -,a
po following reawn.(Section 70415,Business and Professions Code:An ct or �•f/
OZF� y ty TEMP.MEIERORPOLEINST.
cauntywhichrequlreeaperMtromwl 0,alteglmpmv de=Ush,orrepalr
< anystrocturc prior to its Wuance,alsorcqulreathe applIant forsuch permit to POWER DEVICES
LED
V
file a signed nstemeL that M e,licensed pursuant to the pro7000) of the 't
O u'� Contractor's License landPorspter9(mmntendng with eI,towction700e)of Divi-
sion
ivi- SWIMMING POOL ELECTRIC N
HOS alon3o(the Bushes and Pro(esloa Code)orthat hee,ettmpttherclromand
< the baalsfor the alleged exemption. Any violation of Section 70315 by any OUTLETSSWITCFIFSFI 6
applicant fora Fermat.ubjectathe applicant to a civil penalty of net room than
five hundred dollars($50%. NEW RESIDENTIAL ELIk SQ.EI.
ONSIRUCTION
DATE
WWW,�n ❑1,as owner of the property,or my employees with wages as their sole lYP
penmtion,will dothe work andthe structure is not Intended or offered for
O sale(Ser.7064,Business and Profesloa Code:The Conhactara Llceae Law
, $ docs not apply to an owner of preperty who buildsor Improves thereon,and (. OCG GROUIa AES ONUS
who doxmuch work himself orthrwgh hisown empleyees,penvided lhal such
Improvements are not Intended oroffered for sale.If,however,the building or TOTAL:
Improvement Bwld wllhlnomyearofcompletion,lheowner-bulWerwill have
ttt,jZurdenof proving that he did not build or improve for purpose ofsale.). QTY; UMBIN(N'P MIT FEE FLOOD TONE APN
u L A...At of the property,am exclusively mntncting with limnmd PFItMLI. ONCE�F
contactors to construct the project(Sec.7044,Business and Profeasiores Code: `„
The Contractors License Law does not apply to an owner of property wh ALT('R a N k -WATER
Wilds or Improves thercoM and who contact. for each p,.,,.with o .v
agIl[I+ctor(s)licensed pursuant to the Contractor'.Licenx Law. FEE SUMMARY
LJ I am exempt under See B k P C for the,reason BAIX FLOW OTECT.DEVIL
to ITR I no PPFQ
Owner vR;JNS FLOOR ROOF,AREA SANITARY Y N_
Date RECmrI'N
WORKMAN COMPENSATION DECLARATION pp(T(1Rgq.!'EA SCITOOL TAX Y_ N_
[-]I hereby affirm that I have a certificate of consent to.elf-snare,ora RECEIPT N
a
certificate o(Workem''Compemation lunnce ora cerafed mpythaeof(Sec' GAB-EA.SYSTEM• .40(III.ETS PARR FEE Y N
3800,Lab C.)
Policy p GAS FA.SYSTEM-0 4(EA) RECEB'T N
Com any BUILDING DIVISI ON FE ES
Certified copy Is hereby famished. CREAS / USIRL WASTE INTERCEPTOR PLANCHECK PEE
allied copy e,filed With the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' C PAID
COMPENSATION INSURANCE S -SANfTARY-SNRM EA.210RI. DBIC Recei t#
(Thlsaectem need not be completed Lithe permit e,faros hundred dollars
($10(Borless.)that maWATER HEATER W/VENT/ELFCTR ENERGY FEE Y N
I caatify than the Performance of the work for which the,permit is Issued,
I shall not employ any person in any manner w as to became subject to the WATER SYSTEM/TREATING
Workers'Compensation Lw.of CaWomla.Date PAID
z = ApplicaNUTICnt NEW RESIDENTIAL ELMS. SQFr. Date Recei t#
ZO NOulCEamorsuTO LICAMa,aRerrakingpesation this pmvix Exemption,you
mode, be mos subjecttothe Work en'ComprawLsinprovtsiomofthe Labor TOTAL:
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