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S 2550
IIPPUGANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CPPV OF CU1'1 Kr1 NO BUILDING-ELECTRICAL PERMIT NO. BUILDING DIVISION APPLICATIONA'13RMIT PLUMIIING-MECHANICAL S 2550 BUILDING PROJECT IDENTIFICA'I'[ON BUILDING ADDRESS. \ SANITARY NO. APPLICATION SUBMITTAL DATE r`l 1 3 OW "S NAN111: I'll(1Nt'r C1N AC'Itllt'S ME: LIC NO \-It �_ , t - O '- 1 CONTR(11.M ARCHI ELT/ENGIN:FR: LIC NO: _` ADDRESS: AVN X��X V sir Sv r+dC.r / CONTACT': PHONE: 5 V NN�V d,,`` Q Q g p BUILDING PI?R 11T INFO 501+�� QS A.6aY� El Consultant Fres Paid by Applicant(initial) BL❑DC ELECT PLUMB ME❑Ci LICENSED CONTRACT Ok:S DECLARATION QTY, ELECTRIC PERMIT FEE LMS O C Z I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION with Section]exp of Division 1 of the Business and Prnfessmns Cale,and my license is RESIDENTIAL: O O PERMIT'ISSUANCE �WF infullforceand c8<cl.C.3 Q ❑SFDITI ❑PKITCHEN LUMBINREMODI]. UU Licorsc Class Lice `� APPLIANCES-RESIDINTIAI. [-]ADDITION [I PLUMBING PII'li N7-t.{I] Dalc ToS DECLARATION RL ARCIiI"I IiCFS DECLARATION ❑MULTI-UNIT' ❑STRUCTURAL F O PANELS MODIFICATION Z O'er Z 1 understand my plana shall he used in public records OZ`=S UP TO 2IXIAMPS ❑_INTERIOR El CHIMNEY REPAIR ; Lrecn,ed safessiomJ 201.1a)(IAMPS IMPROVEMENT E]SWIMMING POOLS OWNER-BUILDER OF.0 LARATION OVER 1000AMPS ❑BATH REMODEUREPAIR [I DEMOLITION +CQ 1 hereby affirm that 1 am exempt from the Commelor's Liceree law for the _ W3LLF following reason.(Section 703 L5.Business and Professions Cede:Any city or county SIGNS ELECTRICAL y which rc9uires a perni,to closimet,i lmq improve.Jemali,h,nr repair any swcmre NA 1 ma'0; prior In it,issonne,,also requires theunplicnm tiosuch),anion Neosignalsmlement SPECIAL CIRCUIT/MLSC. a ?hnfheixllanwApuremnuuaM1npr�visionsnlalaaComrrmor'sLicenseLuw(Chaprcr9 WO (commencing with Sletion70000 of Division 3 of the Business and Profession Cnde).m TEMP.METER OR POLE .'I'. C.HCOMMERCIAL: k( � That he is vicarm Ic hmimm and me basis for the alleged exemption.Any violation of [j NEW BLDG/ADDITION ElDEMOLITION a1,m-snSection]031.5 by any applicant for a permit subjects the applicant o a civil Penalty of POWER DEVICES TENANT ❑FOOD SERVICES d0 nnnm Than five mardeddill; 1$50x). FZY I PR VIiM1iN'I' x ❑ Lits owner ofthe Pestrac.nntry employees with wages as their solecumpunsrtinn, SWIMMING P LELECTRIC p., will Ao the uork,and the mmcturc is notimendeJ oroRered 6rsale(SttA(/W,Business ,R 3 and Professions Cale:The Common's License Law does not apply to an owner of OUI'LICI' -SWITCHES-PIX'IURES pnslmny who builds or improves thereon,and who d«s such work himaelf or through his own employees,provided Ihm.such improvements are nal Intended or offered for NP RISIDF.NIIAl.ELECFIt SQ IT. kic.If,howevem the Imudingor improvement ix sold wiahmeme'earufcompllinamthe SQ.F-L FLOOR ARI?A $iM) FI'. iter-builder will have the burden of proving that he did nal build or improve for pur- pose of sale). 1,its owner of the prnpeny,am exclusively contracting with licensed commanrs to TOTAL: construct the project(Sec.7040.business and Pinfievsinns Coda:)The Contractor's L a se law d«snot apply to an owner nfpml,eny who nuima or improves thereon,anA QTY PLUMBING PERMIT FEE who contracts natural projects with a mmmcams)licensed pursuant o the Commconsr License law. ' PERMIT ISSUANCE Ilan exempt under Sec. ,B&P C fn,Win,.sen AL'FI7R-DRAIN&V F.NT-WA'T'ER(EA) VALUATION Owner Dalt WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE (y© Q 0 0 I be eby.fino under penalty of perjury one of the following dalam an: jJ ❑ Ihavcundwill maintain a Certificate of Consent to selOinmre for Worker's Cumpen- DRAINS-FLOOR,ROOF,AREA,CONED. S'I"OklliS TYPE?CONSTRUCTION nation,as provided for by Section 3700 of due Labor Code,tin the performmace of the work for which this Permit is issued. FIXTURES-PER TRAP CCyN - a 0 1 have and will maintain Worwes Comp,molan Insurance,as returned by Section J I�IJWI. 3700 ofthelabor Cade,for the perfornumenof?be work fnr which this pemo,is issued. GAS-F.A.SYSTEM.]INC.4 OUTLETS OCC.CROUP APN My Wnrkeh ComPensaliun lnsnnmce crime,.,,it Policy n inher are: Carrier. Policy len: GAS-1iA.SYS'I'EM-OVER d(i?A) A CERTIFICATE OF FXEMPT1ON FROM WORKERS' GRIiASFIINUUS'1'ki,WASTE INTERCEPTOR ,l COMPENSATION INSURANCE. BUILDING DIVISION FEES is,In,,.)Dlis section need nm hecomple¢d iftha Penni?is for one hundred dollals(MaH GREASE TRAP 1'hANCHIiCK ETF: I lenity(but in he performance offhe work fnrwhich this permit is iaaued,Ishall SEWER-SANITARY-STORM F.A.200 ET. not employ any Person in any manners s to become subject tome Workers'Compen- I7NERGY FEF. Z sedan laws ofC`IlNsout,Dmc1� S.[4 N p� f WATIiR HEATER WNENTIFLECI'R O Applicata VV V-- -�1 1 `I N(HICI?'POAPPLICANT:IL uI'mr m,,kin ?hlsC ificmc 'Exam tion, hou1J B B Y°°s WATT?R SYSTF?M/1'RI?ATING a all subject n)the Workds Compensation provisions of[lie Labor Gds,you must SOILS {1a fonovithomad,vithnich provisions or pernitshallM deemed revoked WATER SERVICE G A � Z CONS'1'ki1CT1ON LIiNIIINGACiiNCV NEW RF:SIDF.NTIN.PLMB. SQ.I P D lam RemipX hereby allino that there is a construction lending ogamy bar the peninnomec of UO the wnrk'fnrwhich?his pent,it is issued(Sec.3(y>1,Civ.C.) E' Lemices Name 'f(YI'AI.: Lcndcrs Address TOT I cenify Thin I have read IIs,appl icmin i and same that Its, have monomial is BUILDING FEE r/ai ennui.l agree to emnply with.Deity and county mdineneesand state laws relating l" QTY. MECHANICAL PERMIT y - V Zbuilding construction,and hereby authorize representatives of this city to cover upends, r aMrvcmentioned noncey far inspection purposes. PHRMITISSUANCE We)agree tit save,indemnify and keep harmless the City of Cupertino against ELECTRIC FRIT 1'abilitics,judgmem.,Assistant expenses whiehmay'oury wayaccmeagnioa said City AM 17R OR ADD'IO MECU in meyuence of the granting of this permit. PLUMBING hili 45- APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FEE SOURCE). ULA'flOrA (�V,\y�•-0�p , AIR fIANDLINO UNIT(OV(ik 10.(NIO CPM) CONSTRUCPIONTAX Signature o'AppticamlOontmemr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE HAZARDOUS MATER V S DISCLOSURE Will aheapplicam or future building oecupontame or handle hmnrdeus material HEATING UNIT(TO 100.000 B I U) as defined by the Cupertino Municipal Code,Chapter 9.12.and the Heathens]Safety Code,Scoion 2553200^ HEATING UNIT(OVER 100,0 U) ❑Yes i � VENTILATION I'AN(SIFBISIDE PAID „r0 ' Date RecerplX Will the applicant or favus Wding occupant use equipment or device%which OOILER-COM, 'OR 100.000 BTU) ,f hlrarden sir contaminates'ai de0nc l by,he Bay Ara,Ai,Quality Munrgenetl TOTAI, Uisvicl" l,vi ❑Yes nye BOILER_CIp(OVER 100,NX)HTU) a4 I I have real the harmdon.ntmaials rcuumbirms and,,Chapter 6.95of the Cali- AIRC DITIONIiR ISSUANCE DATE? tbml,,Health&Sntary Calc,Sellinr112550.5,25593 and 25534.1 understand Ilya if,he sW RI9SIDENI IAL ME-CH. SQ.FI'. talking low,no,currently hove,,mnam.Ila,it la or,nevpmsdisunion lyllicverms.a of the myuirrycntswhichynu." ce eta CeniOcam of(kcuparcy. Owne"andinorised agent Doe TOTAL: ISSUEDBY:1„/�/ &949:f � OFFICE