26701 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO APPLICATION/PERMIT PLUMBING-MECHANICAL PERMITNO. 0
BUILDING DIVISION BUILDING PROJELT IDENTIFICATION
B^U�IL••DING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
Va VW F• 1 ' 'p UNIT# LOTIr S
NAME: ONE- 0� O RgCI'OR'g N N/C 1rCONTROL p
R I III ECT/ENGINEER: LIC NO: e>1DgRBSS11 1 , V O�� ❑
'ONTACT: PHONE: 1i 11 f� T 5h'
QTY ::'"` `"ELECFRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE E] 13 ❑ t�5
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ppez I hereby affirmthat l amlicensed underprovisions of CTsigai(cornmeacing with
FQ O0 Section 7000)of Division 3 of the Business and Professions Code,and my license is in PANELS
f 41 Poll force and of UP TO 200 AMPS
q.
F 2 W Licari las• Lic.N `¢
m<y Date Commmor 201-1000 AMPS
ZOrD ARCHITELTS D• A TION OVER IOW AMPS
SQ.FT.FLOOR AREA $/SQ.FT.
O Z-^® I understand my plans shall be used as pu tic records.
¢� SIGNS ELECTRICAL
'�� Licensed Professional
�ty�< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
MU 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
ma following reason.(Section]031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
ON.] which requires a permiM construct,alter,improve,demolish,or repair any murnme
prior to ms issuance,also requires theapplicant for such perniuo files segued statement FEWER DEVICES
that he is licensed pursuant to the provisionary the Contractor's License Law(Chapter
❑L 9(commencin with Section 7000 fDivision 3o he Business and Professions Cade SWIMMING POOL ELECTRIC
xo (commencing )o ) VALUATION
W❑y or that he is exempt therefrom and the lforth eged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
_ ¢ Section 7031.5 by any applicant for a pe its el eapplasinttoacivilpeneltyof
2. 0
not torte than five hundred dollars 1$500 NEW RESIDENTIAL ELECTRS FT.
� so ❑ Lasownermftheproperty,or top 'with ague in ompensation, Q' STORIES TYPECONSTRUCDON
A. will do the work, the sou n endedorofferedfor a ec ,Business
and Professions C e: a on is License L not a to en owner of
pmpertywha -ildm sthe and o sue work himselfeadmoughhis
wemx
om ployon atsuch//////ffffffyyaaaap ep is mteadvelmidferedfrrade.If, OCC.GROUP RES.UNITS
hextsc,thebuil mg r provem ssI ithin one year ofcompletion,theowner- TOTAL:
builder will have the b nofprovin Ih hedidnotbuildorimpmveforpurseseof
sale.).
❑ I,as ownerof rhe property,am ezclusivclycomraaing with lianscd conoactorsto QTY' ------ML-00DZONE AT'N
PLUMBING PERMIT FEE
construct the project(Sec.7044,Business and Professions Code:)The Convector's
License Lawdoesnot apply roan ownerofproperty whobuilds orimprovesthereun,and PERMIT ISSUANCE
whocommets for such projects wirhaveammatons)licensed purmantmthe Contractor's ALTER FA FEE SUMMARY
License Law. ( )
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE O SIDE FEES
SANITARY Y N
Owner Date DRAINS-FLOORROOFAREAGONDRECEIPP#
, , , .
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
1 hereby affirm thin I have a certificate of consent to self-ins......cerificam of RECEIPT#
keys'C�ompismamiim,IInes�urannceie,in.certified copy thereof(Sec.3800,Lab C.)which FlXTURES-PER TRAP PARK FEE Y N
Policy#1._IV lJ�-Y It\�V D3 RECEIPT#
GAS-M.SYSTEM-1 INC.4 OUTLETS BUILDING T It FEES
Cmmpuny y - , GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK PEE
ertifiW Dopy is hereby Pomished.
CirtifiW copy is filed with the city inspection division. GREASEONDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRBASETRAP SOILS FEF.
COMPENSATION INSURANCE
(This section neednot be completed ifthe permit is fmone hundred dollars($1W) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less)
I certify that in the performance of the work far which this permit is issued.I mull WATER HEATER W/VENT/ELECR
not employ any person in any rammer so m.0 beacons,subject m the WorkersPAID
Compensation Lawsof California. Date WATER SYSTEM/1REATING
Applicant Date Receipt#
Q z
C) NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
f/1 become'ubjectlo the Worker's Compensation pirvismnsofthe Labor Cod,you must
tYi forthwith comply with such provisions or this Rental shall be themed revoked. BUILDING FEE
aCONSTRUCHON LENDING AGENCY SEISMIC FEE
Z I hereby affirm that there is a construction lending agency for Ne performance of TOTAL: ELECTRIC FEELT. Lender's
U O the work for which this permit is issued(Sec.3097,Civ.CJ
Name PLUMBING FEE
Lender's Address QTY. MECHANICAL PERMIT PEN.
U I certify that I have read this application and state that the above information is MECHAMCAL FEE
correct I agree to comply with all city and county cminances and state laws miming to PERMIT ISSUANCE
building construction, it ction, herebyaulunizerepresematives minis city menva,minthe CONSTRUCTION TAX
U 7 alwve-mentioned property for matite iim purposes. ALTER OR ADD TO MECH.
�i (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way acerae against said City AIR HANDLING UNIT(TO 10,00(I CFM)
trance of the grantin of th's pertnh.
1) ` AIR HANDLING UNIT(OVER I QIMq CPM)
ig n1mixApplicamiCurtment, ` a J EXHAUST HOOD(W/DUCq
PAID
HAZARDOUS MATERI DISCLOSUR HEATINGUNIT(TO I00,O00BTU) Date Receipt#
Will the applicantoro Mu buildingde,Chmstore o,hnddle hHealth a material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health end Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Coda,Section 25532nd'
❑Yes 11 No VENTILATION FAN(SING LE RESID)
BOILER-COMP QHP OR 100,000 BTU) ISSUANCE DATE
Will lair co is commitments
building by the Bay Area entnrdevices whichemit _ A p
hazardous air cnntaminenta as defined by the Bay Area Air Quality Management BOILER-COMP(OVER IOO,000 BTU) �i E
D'stric1l C3 Yet
Yea No NEW RESIDENTIAL MECH. SQ.FT. •YO� 7 19
I have mad the hazardous materials requirements under Chapter 6.95 of the Pl Y 95
Califamia H.Ith&Safety Code,Sections 25505,25533 and 25534. 1 understaad that V V �r
ifthe building does not currently have a tenant,that it is my responsibility to notify the (e
occupant of the requirements which must he met prior to issuance of a Certificate of Ul-krf I/NL'
Occupancy.
Ownerormffimized agent Date TOTAL: .0j
0 ISSUED BY:
OFFICE
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO APPLICATION/PERMIT PLUMBING-MECHANICAL PERMITNO. 0
BUILDING DIVISION BUILDING PROJELT IDENTIFICATION
B^U�IL••DING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
Va VW F• 1 ' 'p UNIT# LOTIr S
NAME: ONE- 0� O RgCI'OR'g N N/C 1rCONTROL p
R I III ECT/ENGINEER: LIC NO: e>1DgRBSS11 1 , V O�� ❑
'ONTACT: PHONE: 1i 11 f� T 5h'
QTY ::'"` `"ELECFRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE E] 13 ❑ t�5
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ppez I hereby affirmthat l amlicensed underprovisions of CTsigai(cornmeacing with
FQ O0 Section 7000)of Division 3 of the Business and Professions Code,and my license is in PANELS
f 41 Poll force and of UP TO 200 AMPS
q.
F 2 W Licari las• Lic.N `¢
m<y Date Commmor 201-1000 AMPS
ZOrD ARCHITELTS D• A TION OVER IOW AMPS
SQ.FT.FLOOR AREA $/SQ.FT.
O Z-^® I understand my plans shall be used as pu tic records.
¢� SIGNS ELECTRICAL
'�� Licensed Professional
�ty�< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
MU 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
ma following reason.(Section]031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
ON.] which requires a permiM construct,alter,improve,demolish,or repair any murnme
prior to ms issuance,also requires theapplicant for such perniuo files segued statement FEWER DEVICES
that he is licensed pursuant to the provisionary the Contractor's License Law(Chapter
❑L 9(commencin with Section 7000 fDivision 3o he Business and Professions Cade SWIMMING POOL ELECTRIC
xo (commencing )o ) VALUATION
W❑y or that he is exempt therefrom and the lforth eged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
_ ¢ Section 7031.5 by any applicant for a pe its el eapplasinttoacivilpeneltyof
2. 0
not torte than five hundred dollars 1$500 NEW RESIDENTIAL ELECTRS FT.
� so ❑ Lasownermftheproperty,or top 'with ague in ompensation, Q' STORIES TYPECONSTRUCDON
A. will do the work, the sou n endedorofferedfor a ec ,Business
and Professions C e: a on is License L not a to en owner of
pmpertywha -ildm sthe and o sue work himselfeadmoughhis
wemx
om ployon atsuch//////ffffffyyaaaap ep is mteadvelmidferedfrrade.If, OCC.GROUP RES.UNITS
hextsc,thebuil mg r provem ssI ithin one year ofcompletion,theowner- TOTAL:
builder will have the b nofprovin Ih hedidnotbuildorimpmveforpurseseof
sale.).
❑ I,as ownerof rhe property,am ezclusivclycomraaing with lianscd conoactorsto QTY' ------ML-00DZONE AT'N
PLUMBING PERMIT FEE
construct the project(Sec.7044,Business and Professions Code:)The Convector's
License Lawdoesnot apply roan ownerofproperty whobuilds orimprovesthereun,and PERMIT ISSUANCE
whocommets for such projects wirhaveammatons)licensed purmantmthe Contractor's ALTER FA FEE SUMMARY
License Law. ( )
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE O SIDE FEES
SANITARY Y N
Owner Date DRAINS-FLOORROOFAREAGONDRECEIPP#
, , , .
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
1 hereby affirm thin I have a certificate of consent to self-ins......cerificam of RECEIPT#
keys'C�ompismamiim,IInes�urannceie,in.certified copy thereof(Sec.3800,Lab C.)which FlXTURES-PER TRAP PARK FEE Y N
Policy#1._IV lJ�-Y It\�V D3 RECEIPT#
GAS-M.SYSTEM-1 INC.4 OUTLETS BUILDING T It FEES
Cmmpuny y - , GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK PEE
ertifiW Dopy is hereby Pomished.
CirtifiW copy is filed with the city inspection division. GREASEONDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRBASETRAP SOILS FEF.
COMPENSATION INSURANCE
(This section neednot be completed ifthe permit is fmone hundred dollars($1W) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less)
I certify that in the performance of the work far which this permit is issued.I mull WATER HEATER W/VENT/ELECR
not employ any person in any rammer so m.0 beacons,subject m the WorkersPAID
Compensation Lawsof California. Date WATER SYSTEM/1REATING
Applicant Date Receipt#
Q z
C) NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
f/1 become'ubjectlo the Worker's Compensation pirvismnsofthe Labor Cod,you must
tYi forthwith comply with such provisions or this Rental shall be themed revoked. BUILDING FEE
aCONSTRUCHON LENDING AGENCY SEISMIC FEE
Z I hereby affirm that there is a construction lending agency for Ne performance of TOTAL: ELECTRIC FEELT. Lender's
U O the work for which this permit is issued(Sec.3097,Civ.CJ
Name PLUMBING FEE
Lender's Address QTY. MECHANICAL PERMIT PEN.
U I certify that I have read this application and state that the above information is MECHAMCAL FEE
correct I agree to comply with all city and county cminances and state laws miming to PERMIT ISSUANCE
building construction, it ction, herebyaulunizerepresematives minis city menva,minthe CONSTRUCTION TAX
U 7 alwve-mentioned property for matite iim purposes. ALTER OR ADD TO MECH.
�i (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way acerae against said City AIR HANDLING UNIT(TO 10,00(I CFM)
trance of the grantin of th's pertnh.
1) ` AIR HANDLING UNIT(OVER I QIMq CPM)
ig n1mixApplicamiCurtment, ` a J EXHAUST HOOD(W/DUCq
PAID
HAZARDOUS MATERI DISCLOSUR HEATINGUNIT(TO I00,O00BTU) Date Receipt#
Will the applicantoro Mu buildingde,Chmstore o,hnddle hHealth a material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health end Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Coda,Section 25532nd'
❑Yes 11 No VENTILATION FAN(SING LE RESID)
BOILER-COMP QHP OR 100,000 BTU) ISSUANCE DATE
Will lair co is commitments
building by the Bay Area entnrdevices whichemit _ A p
hazardous air cnntaminenta as defined by the Bay Area Air Quality Management BOILER-COMP(OVER IOO,000 BTU) �i E
D'stric1l C3 Yet
Yea No NEW RESIDENTIAL MECH. SQ.FT. •YO� 7 19
I have mad the hazardous materials requirements under Chapter 6.95 of the Pl Y 95
Califamia H.Ith&Safety Code,Sections 25505,25533 and 25534. 1 understaad that V V �r
ifthe building does not currently have a tenant,that it is my responsibility to notify the (e
occupant of the requirements which must he met prior to issuance of a Certificate of Ul-krf I/NL'
Occupancy.
Ownerormffimized agent Date TOTAL: .0j
0 ISSUED BY:
OFFICE