S 3846 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 3846
BUILDING PROJECT IDEN11ricsTION
BUILDINGADDRESS: SANI'T'ARY NU. APPLICATION SUBMITTAL DAT
7-113S LaGuretta Drl'✓e 6„ c?
OWNER'S NAMIi: ONE:Q' CONTROL
NAME: LIC NO:
t 1/I GtU r• ` / S G1.0?� // ,-Q�j� SIC COROL a
ICHITEC MNGINEER: IM LIC NO: O ADDRESS:
I -Tand C-!3 a El
CONTACT: PHONE: BUILDING PERMIT INFO
e2-Z)
^yC 7102
D ❑ Consultant Fecs Pail by Applicant(Initial) Bu❑yG— ELECT PLU1= MECH_
LICENSED CONfRACI'OR:S DECLARAHOON QTY ELECTRIC PERMIT FEEawz E2"
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
WOO with Societe 9W()of Div,oum Sof he Bminfroand Pmte,,Inns Code,andeny license is RESIDENTIAL:
WOO lith ISSUANCE
F-W. in full force and effect. ❑SFD W L El KITCHEN REMODEL
x_U License Class Lica .... !
6y U APPLIANCES PIAL LMUDITION ❑PLUMBING RISI'IPE
d W Dom Conwaor
f.Oy ARCHITECT'S DECLARATION PANELS ❑hfULTI-UNIT ❑STRUCTURAL
Z O h Z I undersmnd my plats said Ise used as public recnrds MODIFICATION
O�+Z-O UPT0200AMPS ❑INTERIOR El CHIMNEY REPAIR
e ��W Licensed Professionel 201-ITXI(IAMPS IMPROVEMENT 0SWIMMING POOLS
OWNER-BUILDER DECLARATION OV13R It1g1AMP5 ❑BATH REMODEUREPAIR ElDEMOLFRON
yC C Q m m
I hereby alarat I am exempt from the Contractor's Licenu Law for the
%3 A.U dirk wing taboo.(Soman 9131 5,fbmincss;md Podcsslnns Code.Any city ut county SIGNS ELECTRICAL LJ OTHER
at W y which require,a probit to cmntmct,alcor,improve,demolish or Apalr any stmcmre
Ipp'�06 prior to av issuance,also requirestheapplicant forsuch permit file aligned statement SPECIAL CIRCUIT/MISC.
Rte.`) that he is licensed ptmoanuu life pm,isionsnfhc Conttamot's Licaave Law lChaplcr9
Wyvp0 (commencing with Section 903(11 of Division 3 of the Rustiness and Pmlessions Code)or TEAR MITER OR POLE INST.
A.X e tG that he is exempt Therefrom and the bavis for the alleged exemption.Any violation of O EW BLDG/ADDITION ❑DEMOLITION
X Q.
Section 7031.5 by any applicant for a Permit.su ms the applicant ut a civil pmalayol POWER DEVICES NT ❑FOOD SERVICE
notmom than five hundred dollars(5500). IMP`ITOIf IEMT�
EbC ❑I,as owner of Onepngarty,nnnyennployec,wimwsgcv usthuirureconnpensvtinn, SWIMMING POOL ELECTRIC
catE. wllldoshe wok.andthestruchum isnot immrddmoiceed forode(Sec.90L1.Business �THFN\
W 3 c0— and I'Tafesvians Gale:The Comrecmr'%License Law does not apply to an owner of OUTLETS-SWITCHES-FIx TORIES x-1 -.1 i
prnpeny who builds or unfit themon,and who does such work hunwil rr through I J II
his own employees,provided that such improvements art not intended or offered for NEW RESIDENTIAL ELECT'R SQ F-L
IlIn
sale.If.however The bulldingor improvemmnt ix sold withinone yearofcompletion.theREA��r
Pne-builder will have the burden of proving That he did not build of improve for put- s V 41 Sf
a sale.
r el the prnpeny,ane r.rimivel,consorting with lwrnmd volume,..,to )
commta the project(Sm.7044,Business and Professions Cure)TTe Contractor's Li-
tseLaw does notapply matowner ofpropenywho builds orimproves theaomand QTY. PLUMBING PERMIT FEE
who ceramics for such projects with a nnnracue(s)licensed pursuatn m the Contractor',
License Law. PERMIT'ISSUANCE
I ane exempt under Se. .B k P C for this reason
Owner' Dae ALTER-URAINffi VIiNT-WATER(LA) VALUATION
WOR :S MI'IiNSAfIUN IlEC1.ARA'1'ION IL\CK Iq.(lW PIt(YI'ECT'.DEVICE
1 Lim by aff,.under penult,of perjury ane of the following deeliatirroe
❑Those anJ will nainmin aCcnilienenf Cnnscnvn Welt-inwref�r Wnrkee,Compel- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
,alien,as provided for by Section 37W of the labor Code,for the performance of the
week for whwh his permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Writer',Compensation Inaum..r.as required by Sicilian
37W ofthe labor Code,for the perfotmameof the work for which this Profit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLET'S OCCGROUP APN
My Wreker's Compensation Insurance carrier and Policy number ver, -
Carrier: Policy No: GAS-L'A.SYS'TE'M-OVP,R 4(IiA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASP/INDUSTRL WASTE:hYILRCEPTOR
COMPENSRIION INSURANCE BUILDING DIVISION FENS
(ibis version need not he completed tithe permit is frrone hundred dollars($100) GREASE TRAP
ur less.l PLANC KI'IiE -3 7 a V
Treaty that in the anyimnnero the work as
subject
bjech tto perthe it Workers
issued.Counter- SEWER-SAN ITARY-STORM EA.200 PT.
not employ any person in any manner m as m become sMjeruo the W'orkerz'Counter- ENEft F.E "3 ED
Z avtion[,."0 Cal'dorni..l),I. WATER DEALER WNFIDDiLECTR
Z Q Applicata GR I r FEE
rNi NOTICE TO APPLICANT:If,utter nuking this Ccndietle of Exemption,you should WATER SYSTEM?RF.ATING
Irenmc object In the Worker'.,Compemmion provisions of The Labor Code,you nnnt SOIL /:E
mod""ith Comply vdiasuch pmvisiens or this permit shall Na deemed revoked. WATER SERVICE
a �
CONSTRUCT ION LENDING,AGENCY NI?W RESIDENT FIAT.FLMB, SQ.IT, PAID
U p Ihereby affirm[hat is a construction lending agency for the Performance of Date R°`cnptx
Ds Ibe work liar which this permit is Issued(Sec,3097.Civ.C.1 TOT
Q U Fenders Name O
C) W Lerdcr'x Address TOTAL:
y 1 reedy that I have rear this apphvcnfon and state that the above information i, BUILDING CC
FN correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
SEISMI
U z bnildmgcomiructienaal hereby aumnrim representatives ofthis city beater upon the E
alcove-mentioned property for inspection Purposes. PERMIT ISSUANCE
(we)agree,.,ave,indemnify and keep homdc,s he City of Cupertino against ELE I EE
habiliie,,judgments.esatsaadesprnwswhicbmnymanywnyncemcagaiml,aid City ALTER ORADD'I'OMECH.
in asequence of the gaming of this perbit. I'1, GPEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT ITO 10.0W CFM)
SOURCE RE JLATIONS. �nJ ME NICAL FEE
✓ � AIR HANDLING UNIT(OVER 10,0110 CFM) COI' t LICITON TAX
Signal mApplica an amor late EXHAUST HOOD(W/DUCT) ITOUSI. MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or from building occupant smre or handle hazardous material HEADNC UNIT(TO 100.01)BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Bcahh unit Safety
Corp.Section 2553200? HEATING UNIT(OVER 000.000 IT IU)
❑Yes ON. VENTILATION FAN(SUGLE RESID) PAID Date Rmcipta
Will the applicant or lime,building occupant use equipment or devices which BOILER-COMP(3HP OR 100,000 BTU)
mit Earned..,air emmmitmnt,as defined by he Bay Ara Air Quality Man oilibr n
r
Diafur 9 BOILER-COMP(OVER I(IgU0rif it TO)
❑Yen ❑Nn
AIR CONDITIONER
Thaw Sabel'humminuvlime, aR 5.25533 under CM1aptcerstgofho Coli- ISSUANCE DATNj, p
fumia Health ffi, tow Cede.Satires 255f1A 25537 and 25534.l understand rte if Ne NEW RESIUIiNfIAI.MECH. SQ.FlL
M1uilding does not currently have jmmnt,thiodisnece.l.ihi ra ,n notify the oncy.
of thert9 r nenU It a�Rn fie nmUtrinr Tn issuance nl uf;enilir le of O�cuPanncy.
) renmllim, v )J,nc TOTAL: ISSUED BY:
OFFICE