S 0874 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PE$A11T NO. 0874 874
BUILDING DIVISION APPLICATION/PERMIT PING PROG-MECENTIFIC lel
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO TLICAIIONSUBMIYIAIADATE
210&q Ht*Jre C,—,r
OWNPR'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
L N e 1 NIQt4 .rN NIC CONTROL#
RCHITIEC1'/ENGINEER: I TIC • / ADDRESS: ❑
J d LunJJ
CONTACD PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELE PLUMB MUCH
.J••V/
LICENSED CONTRACTOR'S DECLARATION Q•I•Y, ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(cammenceing JOB DESCRIPTION
IQMZ with Section 700x0 of Division 3ofou Business and Professions Cache.and my license is RESIDENTIAL
F00 in PERMIT ISSUANCE
force and effectAOWL ❑KITCHEN REMODEL
IU� License Class Lir.# APPLIANCES-RESIDENTIAL ADDITION El PLUMBING RIYPIPH
4 Data Commmar
[[..7m ARCHITECTS DECLARATION PANELS OMULTI-UNIT ❑STRUCTURAL.
Z O�7, I understand my plans shall he used®public records MODIFICATION
DP 10200 AMPS
OZFQQ [IINTERIOROCHIMNEY REPAIR
r,�J,.ul Licensed Pm(essianal 2014 TXX)AMPS IMPROVEMENT C]SWIMMING POOLS
g g g[�- OWNER-BUILDER DECLARATION OVER HAND 0 AMPS O BATHIMA 9n1 1 REPAIR O DEMOLITION
I hceby affirm that I am exempt from the Contractor's License Law for the
06 U following reason.(Section 7031.5,Business uad Professions Code:Any city or county SIGNS ELECTRICAL E OTHER
3 tL which requires v permit to construct,alter,improve,demolish,or repair any sou on-
0:7 prior in in issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
Z that he is licensed pursuant n the Provisions of the Communes License Law(Chapter 9 ITVYT
% GAO (commencing with Section 7")of Division 3 ofthe Business and ProfemionsCcale)ar TBMP.METEHORPOLEINST. /
a ea 2' that he is exempt therefrom and the basis I'nr the alleged exemption.Any violation of 61QW BLDG/ADD( El DIiMOi.ITION
^ Section]031.5 by any uppliwm fnrapermit mhjcros the applicant to a civil Penalty of POWER DEVICES `', r
s„ not more than five handled dollars($501h. ❑•IMPROf [A/y El 17001)SERVICE
� OLa ownerof Ne pmpeny.or my employecawidt wages ns their aolecampensatiun. SWIMMING POOL ELECTRIC IMPROVEMEN'�/IPV
will dothe work,and Ne immure is nm intendedornEered formic(.Sec.7014.Easiness OTHER
Land Professions Code:The Contractors License law arses not apply to an owner of OUTLETS-SWITCHES-FIXTURIS
.. property,who builds or improves thereon,unit who does such work himself or through
his own emplayces,provided that such improvements are not intended or offered for NEW RESIDENT]AL ELI?