S 0978 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEcrRICM• P ITNO
BUILDING DIVISIrQs APPLICATION/PERMIT PLUMBING-MECHANICAL 0978
BUII.DINCPROJIICT IIVNTIFICA'I'ION
BUILDING ADDRESS: / SANITARY NO. APPLICATION SUBMITTAL DATE
/A%/S7� -1 �/YI"✓ �I�-,�QV�Np1E�/�^(�r-j� �•
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CHI FC"/pNGFNEER; LOU NO: /���V!/P� V ❑
'HONE: BUILDING PERMIT INFO
❑ Consultant Fres Paid by Applicant(Initial) HLIK HLECT PLUMB MECH
0 2sS-S5a XS CONTRACTORS DECL ATION QTY ELECTRIC PERMIT FEE
I hancby affirm shot 1 am licensed antler pruvi.iom of Chapter 9(summering JO DESCRIPTION
OaZ with Section 7000)of Ditition Sof the Bminessund Profn,ionsG le,and mylicense is RESIDENTIAL:
won O PERMIT ISSUANCE
F W U in full force and eRec@ ]SPDW h - ❑KITCHEN REMODEI.
QZW License Cl ss y—{� Coro •APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RC-PIPIT
cn<L Dale—��(-F,i-��A.--Convunnr
ARCHIT'ECT'S DECLARATION ❑MIJIThUNIT ]STRUC'TURAI.
~y Z 1 undemand i plans shall he used as public hemi PANELS MODIFICATION
02=0 - UP T02W AMPS
El INTERIOR ❑CHIMNEY REPAIR
E•E W Licemed Professional 201-11"AMPS IMPROVEMENT C]SWIMMING POOLS
^g ; OWNER-BUILDER DECLARATION OVER IOW AMPS ]BATI I RHMODEURP,PAIR ❑DEMOLITION
S' <, I hereby of r4.n that I am exempt from the Commemfa License Law for the
a O a V follown Section 7031.5.Business and Profcsluns Code:An t t ❑I}I'l1ER
�d g reams.(. y city or county SIGNS ELECTRICAL
u1 Oy which requires.permit to cultural,alter,inti demolish,or repair any swmure
prlorm its issuance,also requires the applicant for such permit to l'dea,igarsl statement SPECIAL CIRCOTI7MISC.
that he is licensed pufmanu.due provisiumnfshe Commaors License Law(Chapnr9
ala GAO (commencing with Section7fl(shoUivision 3 oflheBminesand Prefessiona ColOuT TEMP.ME'IT:R OR POLE INST. COMMERCIALa y Y that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NF:W HLDGIADORION ❑DEMOLITION
LLXl W Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of POWER DEVICES TENANT El FOOT)SERVICE
y l more than rive hundred dollars O500L
1-z6 �l.as owns man,Timidity,or my employees with wages astheir mica,mpensation,
SWIMMING POOL ELECTRIC IMI'ItOVEMEN'f
will do the work,and the structure is not intended oroi&red for sale(Sm.7044,Business �� ❑OTHER
a1 and Professions Code:The Contractorply m n
'.License Law does not apply nwner of OUTLETS-SWITCIIIiS-FIXT;I
prnpenY who builds or improves(harem,and who does such work himself or through
his own employees,provided that such improvements um not intended or offered far NEW RESIDENTIAL ELECTR PI'
sale.If,however,the building or improvement is sold within nncyearofcompletian,the piS� :. FLUURAREA SISQ.IT.
owner-builder will have the burden Of proving that he did but
build or improve for put W pa(�
pose of sale.). '1'Ol'A I: u
I,as owner of the
pmexclusively contracting withslicensed ncontractors
cameo(he panes.(Sac.70414.Business
nbuCmde)The reoLt-
crime Law does net apply man aofproperty who huidmrimvasthereon,and QTY. PLUMBING PERMIT' 1°EEvhncanwesfrsuchpmjrKwithuconimetars)licensed pucvmt notdeConatcmr'v
U
rGn,1N
License law. PI;RMIT ISSUANCE
I]I am exempt under Site .R&P C for this reavm
ALTER-DRAIN&VENT-WATER(FA) VALUATION
Cal UamO
WORKER'S COMPENSATION on DECLARATION BACK FLOW PROTECT.DEVICE ��
1 herebyaffirm under penalty to perjuryoneofthe bdhre for Wdamsone
(have nndwill maintain ell a 37th of the 1-mar sel Code.
Workersce it he DRAINS-h1.00R,HOOF,AREA,COND. STORIES TYPE CONS'1'RUCTION
work for
pnrvided for by Ss issu 3700 of the lalbnr Cndq for the prrhtmmnce nl thr
rk forwhich ill maintain
isissued. FI%TURIi.S-PER TRA I'
.apt 1 have and will ode,fon Wnrkcos ante ofshe a rk for ce,which
h required by Section
9JW of the labor Code,for the performancc of the work for which this permit is issued GAS-EA.SYSTF.Ab1INC.4OUTLETS OCC,GROUP APN
MY Workers Compey. nnsew rnnA PnlicY nlM�al�[L'2!/JY_
Cancer.iuyynxur rric Policy No.: I✓_1 {�- 7�W GAB-IIA.SYSTEMOVHR4(I:AI
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASI%INDUS'TRI.WASTE.INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISI ItiCS
("Fas,rdon na,d not he am,plated ll'IM1e panniYix frn onehundreA Anllum($10b GREASH'I'RAP
or less.) PLANCI IECK FEIi
Toy an, const in any
rrel sun,
subject 1.thaWier,'C.lshall SEWER-SANITARY-STORM ITA.200 17F.
nm employ any pecan in any manner so as m become subject m the Wnrkeri Cmnpen. ENERGY FF.F.
O ,Z .mind Lows it Col;fmnin.Data WATER HEATER WIVENVELECI'R GRADING FEE
Z Applicant
rA NOTICE TO APPLICANT:IL after making this Cedificam of Exemption,you should WATER SYSTEMII BEATING
f-' became subject m the Worker's Compensation provisions mf the Labor Code,you must AFEE
US FEE
Gafa forthwith comply with such previ.tion.or this permit stall be deemed revoked WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RI?SIUENTIAL I'LMe. SQ.F7. ID
Z Umc Receipt p
V 5.) I To,which
hithauhere iso ad
lending agency for the perfnnnanee of
Fa work for which this permit is issued(Sea.31RJJ,Civ.C.)
(L lender',Numc TOTAL:
lander s Andress IDTALILDING FEF.
ZI 1 amity that I have read this application and smut that the stawx information,s
t, fg correct.lagree mannply county Fralcodirnces and mia"'y tawerelanin th' QTY. MEQHANICAI.PERMIT buildingcnn.amclinn,and hereby authorize repre.emmtivos nl'Niscity nunmr upon the ISMIC PEE
ahove-memi ara d pmpemy for inspection pinazi PERMIT'ISSUANCE
(We)agreemmvc.indemnify andkcaph less the Coyof Cupeninoagainsl ELECT RIC FEE
Ilabilitics,;udgmems,com.ond cxpcnms which in any way accme against said City ALTER OR ADD TO M ECI.
in conscqucnce the cont .nf lhisp mit
PLUMBING FEE
APPLICAN , D S' DS AN I 'OMPLY WITH LLN N-POINT AIR HANDLING UNI'I'('10IQO[XICFM)
SOURCE ' ON. MECHANICAL PER
AIR HANDLINGtUNIT(OVER 10.000 CFM) CONSI'RUCTION'I'A%
Sign or o A IieanJC wmor Date HXHA USTI HOOD(WIDUC 1) (JOUST NO M TTIGAI'ION 113E
H RIX)US MATERIA(S DISCLOSURE
Willl eapplia nr fuwre M1uilding oecupnnt more nr handlehvardous mamrml HEATING UNI'I'('1'O l llff"BTU)
na der,nal by the Continue Municipal Cade,Chapter 9.12,and the tical th and Safety
Code,Section 25532007 HEATING UNIT(OVER 1Q1,00)HT U)
❑Yex Ik�Nn VENT'ILA'TION FAN(SINGLE RESID) PAI[)
7� Date Reaiplg
Will the applicant or future building occupant use equipment or devices which conmmnants os defined
nit hazardous air iby the Bay Amu Air Qual ly Management ROILER-COMP THP OR 100,000ITYU)
T(YI'AI,:
District? BOILER-COMP(OVER 1010,000(ITU)
(]Vex �No
]),a.mall the lnfeardsumnoon.is requlmmcnts made,Chapter I,95ofthe Cali- AIR CONDITIONER ISSUANCE DATE
fomin Health&Safely Cade,Sections 25505,35533 and 25534.1 undcmand(hal if the NEW RESIDENTIAL MECH. SQ,IT.
buildingducenonc ishich nwaatenant,thm it is my msponsibiliry to nmifytheoccupant
of the mgrircmenO which mull be mm prionoissu.nee ofu Cenificwe of Occupancy.
Owner ,or authorized agent Data TOTAL: ISSUED BY:
OFFICE
VENDOR TEST LAB
BLDG 49E
PROPOSED FLOOR PLAN 1 /4
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OFFICE Con
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