S 0712 (2)APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO Nl11LDlN6 - ELECTRICAL. 111ig`M IT NO.
BUILDING DIVISION APPLICATION/PERMIT O
�
77ao vr.� /9�/v9ow tea:
�2
NIiH:S NAMB: aa C // PHONE: ACIYy)j1'S NAME Q [JC
iNER 7 �U� *&NZ / ! ��S /VV/ 4R--� �N7f t�p'`Q
N'1 KDL#
al
/� ❑
ClIITECT/ENGINI:ER: LIC NO'.DI 20.2 el&o EV014"` -4&"6
4 V �i iL r `�
J•
CONTACT: PHONE:
BUILDING PERMIT INFO
BLDG ELECI PLUMB MF;C'i
❑ Consultant Fees Paid by Applicant (Initial)
�y{-•
EJLICENSED
CONT'RACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
1 hereby affirm tem 1 an licensed ..sof pr ... ..imtx of Chapter 9 (dam milli„ g
MZZ
wird Sermon 7IX0)of Divisi.n3ol the Rosiness and Endes.inns Csde. and my license is
RESIDENTIAL
WOO
F g,
PERMIT ISSUANCE
in full h+reesond R
❑ SFDWL ❑ KITCHEN REMODEL.
C U I-
iEU
p. Z M
Licenu Lia # APPLIANCES-RE:SIDENTIAI.
Dam Contra,,.,
[]ADDITION [I PLUMBING RIi-PIPE
❑STRUCTURAL
MODIFICATION
vista❑MULTI-UNIT
F 71n
ARCHITECTS DECLARATION
used as public records
I understand my plans shall Mu
TO
UP T02(N)AMPS
UP 2
❑INTERIOR ❑CHIMNEY REPAIR
7p11'ROVEMENT E] SWIMMING POLLS
{=I:.t.O
Liccnsnd Promoionrl 201-1000AMPS-
CC''
OWNER-1311TLDERDPALAKA'110N OVERIfNN1AMPS
from Contractor's License Law for the
❑DIiMOhI'IlON
1C�
I hereby allino that I not exempt the
Q}uJ�'(,THRI?MODEL/RI:PNR
M HER
XV
a
following rcvsoo. (Section 7031.5. Husiness end Po4c,oun. Core, Any city or county SIGNS ELECIRICAL
E, m y
which myuims a permit m con%mmt, alter, improve, demolish, or repair any swemre
HO�
prior o its issuance. also requires theappliczm mrowhp mann to Bh,.,E,mdomeme.t SPECIALCIRCUIT/MISC.
COMMERCIAL
i }
that he is licensed pursuant o the Provisions of the Commi Licenx, Law (Chapter 9
Ed
moniumming with Section 7000) of DNimon 3 of the Business and Professions Code) in, TEMR METER OR POLE INST.
c
a a e g
that he is exempt themfrom and the basis for the alleged exemption. Any violation of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
Section 703 L5 by any applicant for a Permit subjects the applicant In a civil peird"of POWER DEVICILS
C1 TENANT ❑ FOOD SERVICE
^'I
I more than five hundred dollars (5500),
SWIMMING POOL IT LELTRIC
IMPROVEMENT
p❑Las
owner of the property. or my employe„with wage,.. Neir,olemaopamlatian,
�D'IIIIiR
will do the work, and the stnmmm is not intended or oforod art safe (See 9044. lhoir`x
f^,�F
at
4'
unit Ihnfeewmus Cmle:'Ne Contmdnr's License ].me does not apply ,, on owner of OUTI.ISI'S - SW ITCHES -FIXTURES
P
prupedy who build, or Improve, Ihcrean, and who does such work himxlf nr Ihmugh
NEW RESIDENT [At, E3LECTR I SO 14.
his own employees, provided thatsuch improvements arc nor intended or offered for
QwFT FLOG A I'
SISQ.I•I'.
sole. lL however the building., improvement is.nld wiflu., eYemu complcrinn, the
r -builder will have the burden of proving that he did our build or improve for par-
Arc C
I, as owner of the n exclusive) contracting with licensed contractors TOTAL:
❑ y, nm y ern rec mg wi
Core;)'Hs Contractor Li-
n s
Cary
(Jh
e msuuct rba prone, (Sec. 91X9.
Sec. and Profession, ha and PLUMBING PERMIT FEE
L`.
..owner of l QTY.
u wLawdoesnouhptyn+an
comefpropeny whobudnsmhmprothe
rrk��ryo
Coulos.and
cunancu hx.uchp jeers with uetimrucen(e)liccnud punvmm ,.the Cnnvecuo',
withac
License Law. PERMIT ISSUANCE
❑ I vat exempt under See. . 11 & P C for this rvamn
ALTER & VENT- WATER (EA)
VALUATION
-DRAIN
Owner Dam
WORKER'SCOMPENSATION O[CLARATION BACK FLOW PROTECT. DEVICE
•
1 hereby affirm under penalty of perjury one of N, following dechrouium:
❑Ihave.nd will maintain.CeniOcam of Conscmmsdf-inwre for Worker's Co.,..DRAINS- FLOOR. ROGER AREA. COND.
STORIES TYPE CONSTRUCTION
,:than, as provided for by Section PW of the Labor Crile, for the performndec of the
'IRAP
work for which this pcmit is issued. FIXTURES - PER
E]I have unitwill mniaain Worker's C.mpenaairm hounntea as required by Section
'1
3700of the Fah nr Cod, fo,deperfonnunc,nfdo work lin whidrthis permit., issued. GAS - EA. SYSHM -1 INC. 4 OUTLETS
OCC. GROI➢' MIN
My N'orkky�l.C��nmjj�� sum�pi��- ryLs and Policy nu
�� GAS-G.SYS'1IiM{)VER 41F,A1
Cvrticr47�/Jj_E Y!/A%Leamc Policy Nn.:
/
CIiRTIPIC O PENSA ION INN FROM WORKERS' GREASFANDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE
BUILDING DIVISION PEES
(id, section nerd not he aamplmed fthe pc.oil is for.., hundred dollars Pi 100) GREASETRAP
1'LANCIIIiCK FEE
�
nr toes)
leenifythal inthe performance of the work forx'hich thispennil is komd. l shall SEWER -SANITARY- ST ORM EA. 2(X114.
ENERGY FEE
sol employ any person in any outaar sit us m bscmmc whjeat m the Worker, Coml'ed-
GRADING FEE
Z
z O
cation Laos of Gdiliarnm Doc WATER HEATEIR W/VENT/ELECR
Applicant
NOUCETO APPLICANT If, fl,, making this Ccnificm,of Exce,16-n. you Sheard WATER SYSTEM/1'RI?A'rING
r -t
;