99080188 _ APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY CUPBUILDING-RLE( L
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECH48N:,LAI
-ROJETIDIUILUINCCA
TION PEYRt MII /
BUILDING ADDRESS'. SANITARY NO. APPLICATIONSUBMITTALDATI
11 Zn �l r dale u ...d - 2 ( .-?7
OWNER((")SS)N ME /� PIIONEy- ,}- CONTRAC/l'�O{�'S N.A�M E:_- LIC NO: /
RA�QY LI1 G C^ 1 M1� VVW�r NIC ✓ CONTROL#
\RCHrLECf/ENGINEER: CNO: ADDRESS: ❑
'ONI'ACI': PHONE: BUILDING PERMIT INFO
�4a jy _J ❑ Consallant Fees Paid by Applicant(Initial) BLW ELECT PLUb1B h1E❑CH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE LJ/ Lr�Jf rLJf
1 hereby alum mat 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
DaZ with Sedon2000)of Divisionlofdhe liurinu.and Professinlu Cale,.nd myli Cr,c is HF ID NTIAL:
WOO PERMIT ISSUANCE �_
F-ad in full force and effect. ❑SFDWL ITCHEN REMODEL
a U(F5 License Class oAPPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE.
h Q L Da1C CCum
FDN ARCHITECTDECLARATION DECIARAHON VANIi1,5 ❑MDI%6UNIT ❑M(DIFIURAL
CNI]O
Z p m Z I understand my plans shell be used as public records MODIFICA'T'ION
OZ=- UP T0200AMN5 [I INTERIOR ❑CHIMNEY REPAIR
F 4t:ul Licensed Prat—i...ml 201-100JAMPS IMPROVEMENT j]SWIMMING POOLS
zYE= OWNER-BUILDER DECLARATION OVER I"AMPS ❑BATH REMODEUREPAIR [I DEMOLITION
6 1 hereby affirm that 1 am exempt from the Contractor's License Lain lot the
x�x O G O following raison.(Section 731.5,Business.nd Professions Code Any city or county SIGNS ELECTRICAL OTHER
W 3 W vFi which requires a permit to construct,alter,improve,demolish or repair any.memo,
EL C)
prior m its issuance.also reclaims the applicant for.such Permit file a signed statement SPECIAL CIRCUIT/M15C.
�y that he is licensed pursuant cc)the provisions of the Contractor'%License Law(Chapter 9
W Cc Icmnmcndne with Sector 70)(Y)of Division 3 ofdhe Business and Professions Cide)m I'HMP.METER OR P01,11 INST COMMERCIAL'
C.a e C that he is exempt therefrom and the lwsis for the alleged exemption.Any violation of is ❑NEW BLDG/ADDITION ❑DEMOLITION
Wnai Section 2031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES TENA C1FWD SERVICE
f
not more than live hundred dollurs(b500). IMP EMENT S� Ql,as owner ofthe PropetA ter mYem�l�yees with wages un Muirs�lenm,pnx
cution. SWIMMING POOL ELELTRIC
(.. will do the wCk...d mestuedic bond imcedd
emo@red for sale(See JUW.Business .R
L 3 m and Professions Cole:The Contmerors License law does not apply to an owner of OUTI.EffS-SWI'TCHE.S-FIXTURES
pruT,erty who builds or,mproves thereon,and who dons such work himself nr through
his own employees,provided that such improvements me not intended or concord Ino NI?W RESIDENTIAL ELECTR SQ FT
sale.If.however.the Wilding or improvement is sold within one year ofmpletion,the SQ.Fr.FLOOR AREA $/SU.FT.
co
covicer-builtm will have the burden of proving that he did not build or improve for par-
Escyf sale.).
Jas owner,of the propenY•am exclusively contracting with IicenxJ cnntractnrs to TOTAL:
nnsdmct the project(Sec.20414.Business and Professions Ccde:)The Contractor's Li-
ceneLaw does not apply manownet of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEF.
whocontracts forsueh projecs with a cnnvacmrts)licensed pursuant to the Contimerm s
Limns,Low. PERMIT ISSUANCE
❑I am exempt der Sm. .B&P C ur this reason
Owner `� r D AI:1'IiR-DRAIN&VIiNT-WA'1'IiR IRA) VA UAIION
WORKER'S COMPENSATIO DECLARATION BACK FLOW PROTIT DEVICE
I le,,by.(corn,under penalty of perjury one of the following declarations:
I have and will maintain a Ccndfc.te of Consent to self.insure for Worker s Conipen- DRAINS-MOOR,ROOF,AREA.COND,
.tion.as provided for by Section 320X1 of me labor Code,lot the performance of the STORIBS I'YI'E CONSTRUCTION
work for which this permit is issued FIXTURES-PER TRAP
I have and will out b4i it Worker's Compensation houreacc,vs rx,red by Section
3200ofthe Labor Cale,far theperfomeva of the work for which this permit isomer. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP %mss A��O
My Worker's Compensation Insurance carrier and Policy number are: `?
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CEKTIFICAI H OF EXP.MP`HON FROM WORKERSGREASF/INDUSTRL WASTE IN'fERCEI'1'OR
COMPENSATION INSURANCE BUILDING DIVISION ITE.9
This section need not be completed ifthe pcm,it is for one hundred dollars($Loo) GREASETRAP or ICs.l PLANCHECK FEE
i Cenify that judo,pennnnaneeai the work lit which This pencil is"oed.l shall SEWER-SANITARY-STORM EA.m21X)14,
not employ any person in y manner sn as do become subject to me Workers Cmpe
nn- ENERGY PEE
O Z scion laws of CulifnrNa.Date WAfER HEATER WNE.\'T/ELECTR GRADING PEE
z C) Applicant
N NOTICE TO APPLICANT.If,after making this Cenifient of Exemption,you should WATER SYS'IEMOIRPATING
a ; become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
I'nnhwith comply with such provisions or this Pook shell be deemed revoked, WATER SERVICE
a �
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Fr. PAID Dem c •i t x
U p Ihcrcby ulbnn that there isaconstruction lending agency for performance of
the work for which this pendl is i...cd(Sec,31x)],Civ.C.)
D. F-'U Lender's Name TOTAL
r Lender's Address _ IDTAL. BUILDING FEE
I Certify that i have run This appucadnn amt.rare That me tbove infmmm,on lis
Cnnect.l agree to comply with all city and county ordinance%and state luwsreleingm QTY. MECHANICAL PERMIT FEL'
U Z building Construction.and hereby authorim reprewnvztscs of this City m enter upon me SEISMIC PTB
uhovcmcrom ed property far inspection OUH„nce PERMIT ISSUANCE
(We)ugrm e.sive.Indcmndy and keep huedess the City of Cupenmo-TELECTRIC FEF.
liabilities.judgments.costs and expenses which may in any way same against said City ACI'ER OR ADD TO MECH.
PLUMBING FEE
in nsequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(10 10,000 CFM)
MECHANICAL Frei
SOU CE HECULA'1'IONS.
AIR HANDLING UNI r(OVER IB.WOCFM) CONSTRUCTION TAX
ign.luru nfApplia.nVCantmcot )mc EXHAUST I FOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building merponr store or handle bcram usmumrial HEATING UNIT(TO 100.000 BTU)
it,dcfecd by The Cupertino Municipal Cale.Chapter 9.12,and the Health end Safety
Code,Notal..255320)7 HEATING UNIT(OVIR J",000 HTU)
El Yes Fl No VE NT LATION FAN(SINGLE RPSI Of PAID
u+ Ecom or Pimm huddio•oscn t use u t or devices which Dam Receipt p
MIT the
IP b pun ywpmm, BOILER-COMP(31111 OR 100,(XXI BTU)
m
it hadous air Contaminants as defined by The Bay Area Air Quabty Monagnnem TUT
strict?
❑Yes 0 N BOILER-COMP(OV ER 100,000 BTU)
I have read the hmurdaus ncmriWs requiremmix under Chapter 6.95 of the Cdi- A I R CON DI'I'IONER ISSUANCE LATE
food.Healed&Safety Calc.Sections 25505.25533.nd 25534.1 understand did itch, NEN'RESIDENTIAL MECH. SQ.FT _ Q,
buildin docs nm.vnently lu ve a temim.Mn n is my nnponsilany m noef me occuparI r
of n,c rvdrem ms wmchnmst caro t pdorm.sswne-d.cCndb o p
Owner or uumori'ieA nBent Dude TOTAL: ISSUED BY: `
OFFICE