04110042 .I CITY OF CUPERTINO
BUILDING DIVISION PERMIT .CONT"CT- Ok INFORMATION
BUILDINGADDRESS: PERMIT NO
A PERFECT CLIMATE 04110042
11614 IIAM(dLk.,H")rl ML) -- PERMIT ISUE DATE - -
ONE.J.I.` a.A.ci`itin 1v r V J DEi-u�Lta. 03.a VL SANITARY 101 U6 LLCdAROL NO. _
IARCHDIECTrENGINEER: a'=3 C-', v'fi 1-35-13
BUILDING PERMIT INFO '
BLDG ELECT PLUMB MECH _
LOO LICENSED CONRACIOWS DECLARATION -
1 hereby.Tian that 1 am licensed under p om of Chapter 9(commencing Job Description _
^]j with SoSHq�7M))of Di v 3qq[td¢BUSinea euioro Cade.enit liccnuu
< inmlh(9rkandeffect V i ZS(";r
5 j2i Lieenreclars v Lie'" ec�� / b�f2EPLACE FURNCAE & ADD A/C
nhq• Data A CH CS ORLARdirI V) / TILL /
�yaU lundc rid my pinssbell beusedaepuhlic mcards
3 1 en
Licensed Profesvanal
0
o s Oat I am BUILDER DECLARATION C�
I Wmhy v(tim that 1 1. exempt from tW ConconoYS License law for robe
cO following mason Permit t 701.5.Business and Pmfnmudi Code:Any city or s county !
m� which.grans a pemn re uinalmn,eltee imnrovc,demolish,or e pmt any awmum
FZ pilotm its iasmnce,a1mnquire tbe apphant so Contractual hpermit to Rics signed
Law(sotemen UU
< thvWULcemcJ nurmam mthc provisions or so tehe Busjw andemciaw(Chale)or Sq.Ft.Floor Area �Y31 U
w. (commencing
axe with numerical TOW)the basis for the ad BUamcsampt Profnu vi Cndc)or s
y that W u exempt tbertlrom and time anti for the a the pphemon.Any violation of
Section 7031S by any applicant for a permit aubjem dM appLnnt to a civil penally of I ber Occupancy Type
not mere Nan E.hundred doll..($5W) 3 4-Zl yU J, . 0 0
E]I.uawrmv of the property,mmy employcea with wegeas Neu isle compewdon,
will do thc work,and the suuttu e is nmmWded oroRemd for We(Sec.RW,Boomers
and Professions Code:The Counsel License law dam net apply to an owner of Required Inspections
property who Wilds or impremoduceon,andwW dousuch work hsmulfor through his -
owne mptoyeam,provided Out such imprommuso arenountended oroRered frraale.If.
however.the building sir improvement a to within one year of campleuon,the owner-
bmlder will home the burden of proving that be did hot Wild or imprmho for purpose of
sale.).
❑1.as owner of tW property,am amusivcly connecting with licensed commend..
construct the project(Sec.70a4.Bum.and Prolusions Code:)The Contracsori U.
cease law dots not apply to an owner of proper who Wilds or improve the.on,and
who concocts for such projects with a contractor(0licensed tom uenuo the Commctoh
Ltamc Law.
1 am exempt under Sec. B&P C for this reason
Owner Data
WORKERS COMPENSATION DECLARATION
1 thereby affirm under penally of perjury one of the following declanwn:
1 hate and will mountain a CeniEam of Consent mself-insum for Work esCompen-
eon,as provided for by Section 37W of the Labor Code.for the performance of the t
poh for which this Permit is issued.
t"kla.ve and wilt mamtmn Workers Compensation Insurance,n required by Section -
/.°X]Ipof'th0laher Cadc,for the pe ff..nce of tW work for wto Nu pertnnuxual.
My Workers mneea tin 1 apnna came�and Poli -
Cam C��a//olicy No.:
C IMCATE EM PDON PRO ORKERS'
COMPENSATION INSURANCE -
(Thu section aced not be completed tf tbe permit is fmoOc hundmAdolla.(SI(p)'
or Mss)
I comfy that in thc perfamancc of the work for which this permit u issued.I shall not
employ anypermn in any manner sou in became subject to the Workers'Compewdon _
Laws of Cahfomre.Day^
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject in the Worker's Compensation pmvismns of Nu Labor Chat,you mum _
.J0 forlwal,comply with such provisions in this peal ll W decmed.mked.
Z" CONSTRUCTION LENDING AGENCY
aN- I he.b Nco that thc.its coetivcunn lender li io I.thc f
F" Y B .) cY Icr umame of
2' thc work for which the permit u.sned ISec.309'i,Cry C.1 t
Leader's Namr-
=z Lendcr'sA d••
m
U0 1 ttndy that I have mad this application and some that the above information is t
Iy F correct 1 agree to comply with all city and county ordinances and state laws Misting M
C)C.) building e)agree to and hereby yand mpreenovese NUCfCupe enter upon agate
r[Ll aWve-menuaned property for inspection purposes
(-'y
(We)agree to costs indemnify expn and kith hamlets the y se of Cupertino against
h in liabilities.ence or judgments.costs and expenses which mrymany wayucme against svd City
fJZ in eansegnence of NC granting of this permit.
" AP ANT UNDERSTANDS AND WILL COM Y WITH ALL NONPOINT ! Issued ty�q Dace/
S CER TI 11 4 Re-roofs
56rom of Im"carrif nuac.r ic
HAZARDOUS MATERIALS DISCLOSURE Type of Roof /
Will the applicant or future bud st
ding Occupant ore or handle hvardous assured
se, (/defined by the Cupenino Municipal Code.Chapter 9.12.and the Health and Safety
cone.Section on 25532(a)t All roofs shall be inspected prior to any roofing material being Installed.
Will ho rodent rolom.adding occupant tyre equipment m dcvme which "If a roof is installed without firs[obtaining an inspection,I agree to remove
S.'Llre"hnrardnus air cone loon¢.darned by thc Bay Ama Air Quality Management all new materials for inspection.
❑Ye / Nu
I have mad thc harardrms materials mqurmmenu under Chapter 695 of dm Califon
n.Halth&SafctyCodc.Sa 25505,23533md25534 larecoWmdthal Wilding
does not cummly haae a tenant ffiAEitiSmymspnsibi]Ltywnourythexcuputofjhc
mgmrcmcnu which m s tprior.iuuauc a fic`of Occu Signature of Applicant Date
nd rgcF, 1' / I All roof coverings to be Class "B"or better
Ownc r-Cawhorvxd.gem ate g
Community Development
10300 Torre Avenue
N Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
`CL� 1 �
OWNER'S NAME: PHONE #
I GENERAL CONTRACTOR' ovl k&�-( I IVV� FAAXX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information
I ® SUBCONTRACTOR BUSINESS NAME I BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing _ I
I Electrical C�ef- C I(MI R.I P
( Excavation
I, Fencing
Flooring: Carpeting
.I I Linoleum/ Wood
Glass / Glazing
Heating I I
( Insulation 11
Landscaping I I 1
I Lathing I
l
Masonry
Ornamental Sheet Metal I I I
Painting/ Wallpaper
Paving I I I
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal I I I
Sheet Rock I I I
iie
Owner/ Signature Da e
,-, CITY OF CUPERTINO
^UPERTINO PERMIT APPLICATION FORM
APN # 3Q,, � "1 " OG I Dater
Building Address:
Owner's Name: // h #:
16 10
Contractor: /� ]( - a Phone: �i n r �C�S License #:
Contact: ;n ^Lu�( ( Phone: „_ —Jn S r S Cupertino Business License#:
Building Permit Info: 4l(l `f `I
Bldg ❑ E�leectt B--- Plumb El Mech
Job Description: F�i /���
Residential v, /I lSL Commercial ❑
For Residential Installations:
Attic ❑ 151 floor ❑ 2"d floor❑
Adhere to min setback requirement❑
Awor Commercial Installations:
eplacement same weight ❑ Additional weight (structural talcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project^ Type of Construction: � U a (L Occupancy group:
l i
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
y. if
/ pp ile Fee ID Fee Description Fee Group
� BENERGY Energy BUILDING
/ BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit > 10,000 cfm MECHANICAL
—- BREMAIRHAN A/C Units <= 10, 000 cfm MECHANICAL
BREMRECEPT Recptl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL J
l MPERMITFEE Mech Permit Issuance MECHANICAL
C' PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees I BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business Licen A G / BUILDING