23386 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identiflation PERMIT NO.
Building A�drt,.: - - 2 3 3 8 6
C-f. v o ��
Kra ime: c� Innou.
CITY OF CUPERTINO-BUILDING DIVISION /�
�� ontnctor'w, : IP.O Ir.N« APPLICATION I PERMIT (9
BUILDINGS.ECTIUCALPLUMBlN WJZHAMCAL CATEGORY CONTROL
Architect/Engineer. Lie Na
QTY ELECTRICPERMIT FEE BUILDING PERMIT,INFO
Add rocL",�,IewsLno I 1 FERMITI35IIANCE r ._� ❑ ❑
LICm EBanNSED CO TRACTOR'S DECLARATION
thereby
affirthat l amned under pmvmnna of Cbapter9(«xnmrn APPLIANCES-RE�ENIAT, JOB DESCRIPTION
Ingwith Section 700D)0f Dh IsIon3 ofthe Bonder sand PmfrsJmsCude,ancinvy
liana la in full force and effeeL PANES
Lbenec ChD L1e0
Dee Conmactor
ARCHITECI'S DECLARATION M-I 1
�2C I urderahrd my plane shall be used u public r orde. 'O �.FT. RARFA ' !/$.FT.
Z ULicensed Pmfmkrul
�.<
K< OW - ,LDERDEION
Ihembyafflm 1.mex. fmtheC.Maor's oawfatk
IEb1LCIRCNT
ST.r7IQS folbwkgrrtuson. n7WILBumadPro(mbtiCd.:Mytltyor P.ME171t0
4SS mntywhlhrequmapntomd,Otu,bp ,demlbh,ormpdr
anyetr mmpA toihbw ,a LomcquWNeappha tfa w&perm w POWER DEVI
K 5 Ole a dgned ateement that k is Manned pure tart to tk provhkm of the
OwG Comranofe Lkr.Law(Chapler9(mmmenctng with Section 71100).(DM- SWIMMING POOL
30 sbn3ofthe Buskm and Professbm Code)orthat he is exempttherefremand VALUATION
beat a the bat for the alleged exemption. Ary violation d Sectn 7MIS by any X[[JRES
papplicant fora permit aub*U the applicant to a civil penalty d n«mom OUT1,than 1/ 6
fiNhundred dollars%5M. NEW RESID Fn FICIR RI TYPECONSTRLCTION
I,u owner of the property,or my employee with wages as their ante
W�7� oompenaelon,willdothework andtketructuR brat Wended or offered for
O ule(Sec.70µBusbua aM Pm(eebv Cade:Tk Comraciare Wmnee Law
$S doe not.pply toan owner of property'who builds orlmprwethemn,and R
whodoeseuchworkhimselfathwghhisownemploym,p.idedth.t.0 h JEE
RES.UNITS
Improntvemeart nmintended mlorolfe (.reale.ILhoweverthewldkgaImprovrmentteeoldt rden d proving that he dm rot wild or lenprovr(a purposeof seaj. QTY. PLUMBING PERMIT FEE1,as owner of the property,am exclusively amnactkg with Manned FLOOD TO
mnteact.to mrutruct the project($¢,70K Business and Prdmkm Code: PERMfTISSUANCE
The Contractor'.1Jaus Law don nor apply to an owner d property who
wlida or Improve thereon,and who contracts for aueh Mjeets with a AL's-DRAIN&VENT-WATER(EA)
.o.ractorW 11emad pumaant to Ne Contractor:Line.Law. FEE SUMMARY
_ U I am exempt under sec B &P C for" recon BACK FLOW PROTECT.DEVICE
OUTSIDF FEES
/Jl Owner Dee DRAINS-FLOOR ROOF,AREA,ODND.. SANITARY Y_ N_
RFGE
WORCOMP@1SATION DECLARATION
❑1 hereby alflremtbri the I have a artlfkate d consent to self-Insure,ora El(Tl1RFS PER TRAP SCI TAX Y_ N_ '
3an)' of Workeri Compewtlon Irmuana ora artl(led ropy thertof 6ec. RECm'T
800,LAb Lab CJ IGAS EA.SYSTE4-1 INGf 0[7[IEIS PARK FEE Y_ N
Polley a GAS F.A.SYSTEM-0VER I(EA) RECmT'I
gCCy BUILDING DI VIS ION FEES
ertl(Ird copy Is hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR
crtiOed mpy b filed with the my impeetbn dMdm.
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID
3 [-92�7�)
COMPENSATION INSURANCE SEIVFFSANITARY STORM FA ]00FT Date RCCCI 1#
(Thbaecilon need n«w completed ff the permit b for one hundred dollar
(sl00)nrlm) WATER HPATFRW/VENT/ELWM ENERGY FEE Y N
I anm the k the penornuna ry m work forwhloh this peredt a bust,
1 shag rant empty any Lawn k any manner at u to brmme ubj«t to tk WATER SISTFM/TREATING .
wakeni Compenutbn Lwed C.Womla.Date PAID
Z Appllant NEW RESIDENTIAL PLMB. SQFf. Date Recei t#
Z Q NOnCETOA WANT.1f,. erm.Wngthla CMUl teofai -pw.,you
ah ldbemmewbjdwffie Worken'Comprw pmvbbmofthe Labor
TOTAL
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