31037 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
- CITY OF CUPERTINO BUILDING-ELF:CI'RICAL PERMIT NO. 31037�O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDING AOGRESS:
538 �ell;n6�o5'e G� SANITARY NO. AP,—PL1\ICATIONSUBMITTAL DATE
OWNER'S NAME:Z P�NE,.— 0�� ONTRA ) IC •
✓L:H/ 16 q y� NIC CONTROL#
a.
ARCHITECT/ENGINEER: LIC NO; gUDRE /��' O (I✓`�— ❑
CONTACT: PHONE: �� BUILDING PERMIT INFO
14CV__efk ' J7;JiiZ7/0 ❑ Consultant Fces Paid by Applicant(Initial) BLDG ELECT PLu M
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE ❑
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
COz with Section]IN)0)nf Divisinn3nRiepusinecwnA fess Cn e,a my"'cnveis
w�0 in PERMIT ISSUANCE SIDENTIAL•
F-IyF full force and effect^ �(,o.�a?� SFDWL El KITCHEN REMODEL
�FUZU Licenu f/ 7 APPLIANCES-RESIDENTIAL
yQd Dme CTSDc,.. A� ❑ADDITION ❑PLUMBIURAtPIPE
1F-M in A shall b use DECLA,nestaaN'�R ❑MULTIANIT O MODIFISTRUCURH
2 O I understand my plvns shell be used uv public retards PANELS O Z UPTO 2W AMPS MODIFICATION
O - ❑INTERIOR ❑CHIMNEY RCFAIR
I:•41q.t�s Licensed Pmlcssinnul - 201-IODOAMPS IMPROVEMENT
RR''
g1YCl� OWNER-BUILDER DECLARATION OVER I000AMTS [I BATH REMODEUREPAIR ❑DEMOLITION
y I hereby affirm dual I um exempt(loin the Contractor's License Law for the
XJ: following reemo.(Section]031.5,Business anal Professions Cale:Any a1yor county SIGNS ELECTRICAL. 5, 0OTHF�
gWres
W k which reo pert aim
mit to combuslter, prove,demolish,or repair any structure (�
FEN prior to its issuance,also requires the applicant for'such permit o file asign[d statement / SPECIAL CIRCUITIMISC.
that he is licensed pursuant n the provisions of the Contractor's license Law(Chapter 9
u1�aOC (commencing with Section 70M)of Division 3 of N[Business it Professions CodO)m TEMP.METER OR POLE INST. COMMERCIAL:
0. e that he is isimma therefmnt one the basis for the alleged esermbbn.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant for a Permit subjects the applicant o o civil penalty of POW'R .VICM ❑TENANT ❑FOODSERVICE
�} nut more Nan five hundred dollars S500).
pQ ❑ I,as owner uftheproperty,or my employees with wages m their sole compensation, SWI I r OOL ELECTRIC IMPROVEMENT
220., will doth[ImILmd theonactme is but intendedorofferi for mle(Sec.]M4,Business ❑OTHER
W and Prdessiom Code:T'he Contractor's License Law does not imply m an owner of O TLE S-SW Cf S IXTURFS
property who builds or improves thereon,and who doss such work himself or through
his own employees,provided that such impnwemcn6 arc nm imendcd or offered Iia NEW 1791 N'1'IAI. '1'R SQ IT.
sole l(however,the building orimpmvetncm ix sold within nuc ycarof completion.the SQ.FT.t1. RA S/SQ.fT.
owner,01111r will hove the hunlen of proving that he did not build or improve for par
you of owner
APR 1
❑Las owner of the property, i exclusively con eskers with licensed contractors m TOTAL / aYttYl $ ^IFa�aaV
ennswct the project(Sec.]IYt4,Business and Profemions Code:)The Convenor's Li- /s (sv`
me Law does not apply to an owner of property who builds or improves thereon,and TY. PLUMBIC IT FEE b� ' I
who contracts for such projects with a cotmm�ond licensed pursuant to the Contractors Q Vh VVrth IYNO
Liceme Law. ' PERMIT ISSUANCE
❑I am eaempt under Sec. ,B&P C for Nreon
is ono
m,
Dale ALTER-DNAIN&VI?NT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT.DEVICE
I het[byaffrn under penalty of perjury.,of the following declumtiams: . D8
❑Ihave endwill mninmine Cenif¢amof Cnnsnm mulf-insure for Workers Cnmmen- DRAINS-FLOOR,ROOF,AREA,COND.
sation,as led for h Section 3]W of the Labor Cade,for the performance of the STORIES 'TYPE CONSTRUCTION
prick y,
o have
this permit is issued. 17XTURES-PER TRAP
w I has and will cede,far
Worker's Compensation Insurance,its ds per by Section
My W.the Wlmr Cala forthe pe it caace,turd olhe faJryw�hfich Nis permit is issued. GAS-EA.SYS'fF.M-I INC 40VfLEfS OCC.GNOUP AI'N
Car ear penyi>D{.1 gupnlGg ei�e Poll,,Nora&i6�7 6 GAS-EA.SYSTEM-OVER 4IEA)
CERTLLIFIICVCATEE'( EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR BUILDING DIVISION RIM(This nation need nut Is,completed ifthe permit is(almen hundrai donors IS IW) GREASE TRAP'
or less.) PLANCHECK FEB
I cerify that in the performance ofihe work for which this Permit is issued,l shall SEWER-SANITARY-STORM EA.200 FI'.
not employ any person in any manner so as to become subject m the Workers'Co open- ENERGY FEE
zZ section laws of Cahfnmla.Dat[
O Applicant WATER HEATER WNIiNTRi1.F.CI'R GRADING FEE
ti NOTICE TO APPLICANT:IE after making this Certificate of Exemption,you should WATER 3VSTEM/IREATING
H b[eame subject y the Worker's Compensation provisions shall
nl the Labor Code,you must SOILS FEE
forthwith comply with such provisions at permit shall he deemed rtvokW. WATER SERVICE
kill
tCONSTRUCTION LENDING AGENCY NEW RESIDENUAL PLMB. SQ.FT. PAID
V Q l hereby affirm that there is a conduction lending agency for the performance of Date Receipt
UU Newark for which Nis permit is issued(Sec.3W],Civ.CJ
Q Lenders NameO'AL:
Lender's Address TOTAL if"If
r a 1 certify Nat 1 have mad this application and slate that the above iadmmmion 1s BUILDING FEE 641-1 V
�+ TA correct.lagoon to comply with all city an Amunrymdurbineanndsmte luwsmlating m QTY. MECHANICAL PERMIT FEE
U 4building connmctian.and herchy amhofze represenNtives of this city menmr upon the SEISMIC FEE
atove-mentioned property for inspection purposes. PERMIT ISSUANCE. O
(We)agree to nave,indemnify and keep harmless the City of Cupci inn against LLECfRIC Ff:E / I.
Iiahi lities.j uJgments.coots and expenses which may in any way accrue against said City gLTEH OR ADD TO MCCH.
in consequence of the granting of this permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0,000 CFM) �.
SOURCE REGULATIONS. MECHANICAL FE
AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRUCTIl
Signumreof Appliwm/Oomtmcnn Dale EXHAUST HOOD(W/DUCT) HOUSING MITIGA ON FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(IT) BTU)
m Jelined by Ne Copenino Mum 'pal Gds,Chapter 9.12,and the Health end Safety
Cade,Section 25532(a)? /y HEATING UNIT(OVER I W.000 BTU)
❑Yes 1�I Nn PAID
(� VENTILATION FAN(SINGLE RF.SID) Date Receipt#
Will the air contaminants
m future building occupant ase equipment or devices which BOILER-COMP QHP OR 1011.00E BTU) / OD
emit hazardous air contaminants as defined Ey the Bey Area Air Quality Management
Dlshict? / BOILER-COMP(OVER IW,"BTU) TOTAL:
EJ Nn
I hi,, dNe heard/tion maermis AIRCONDITIONER �� _ ISSUANCE DATE
r5,u255 3 an under Chapmr 695 of the if the
(unties Health&Safety Coda Sections 25505,2551]and 25534.1 understand to that if the NEW RESIDENTIAL MECH. SQ.FT.
building dcesn currently haveemnont.Nat it ie my resmunsihiliry mtwdf Ne acumant
afth requi is whit unbemetpriormisnwmcanfa CcniFic cart
Ow c og in ) e TOTAL: ,D ISSUED BY:
OFFICE