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04050062CITY OF CUPERTINO° -�" BUILDING DIVISION PERMIT cONTRACTOR3 FORMATION BUILDING ADDRESS: 0201 AT.HAMRRA A17 ANDREW K MILLS PLUMBING IN ERMIT NO O4O500E2 OWNER'S NAME: PERMIT ISSUE DATE THERESE M R T,F.RTPT,n WAY ONE SANITARY NO. CONTROL NO. 408)938-1395 ARCHITECT +ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 LICENSED CONTRACTOR'S DECLARATION Job Description 1 hereby affirm the 1 am licensed under provisions M Chapter 9 (commencing with secure 70W) of Division 3 of the Busing s and Professions Code, and my Heart, is in full forceand effect. License Class REPLACE WATER HEATER W/TNAK7r -.RU }�+�- S;!;;( \j,"p Cut Came Cunaac,or IJ 0 ARCHITECTS DECLARATION I understood my plans shall w used as public records MAY 2 T 2004 Licensed Professional OWNER - BUILDER DECLARATION I bemby affirm that 1 am exempt form the Convanors License Law for the following reason. (Section 7031.5. Business and Prefessiona Code: Any city or county ��� ®� which requires a permit to emossm,L alter, improve, demolish. or repair any strucwm prior In its issuance. also menu. use applicant for such permit to file a signed su,emen, that he is licensed pursuant In be provisions of be C9mucwri License law Charter Sq. Ft. Floor Area Valuation ,9 (commencing with S"fion 7000) of Division 3 of the Busiaeaa and Professions Cade) Or the, a u exmmpt therefrom and the basis fm the alleged esempuan. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 WN ffiel] O Occupancy Type not mom them five hundred dollr ($500). I, as owner of the property, or my employ= with wages as their role compensation, will do the work. and the awmure is at inended or offered fonaic (Sec. 7046, Business and Pre feuio,u Code: The Conuacwrs License taw does nos apply to an owner of Required Inspections property who builds., imposes Ne.... and who don such work himself ar through his own employees, provided Nat such improvements rte not intended or offered for sale IL however. the building or improvement is to within one year of completion, the owner. builder will have the wrden of proving that he did not build or improve for purpose of tile.). K1, as owner of be property, am exclusively contracting with licensed convectors to mtstruct the pmjen (Sec 7046, Business and Pmfwioos Code:) Ta Convacmr's Li. cove law does not apply to an ouster of property who Wilds or 6oproves therron, and who contracts for such projects with a conv¢tor(s) licensed pursuant to the Comnmors License law. ❑ l am ex t� B & P C f thi$ moon S,Ssee /� Owner lYW—� f0(. wry LA WORKERS COMPET�SATION DECLARATL L hereby affrnn under penalty of perjury ore of the fallowing exclamuans: I have and will maintain a Certificate of COn¢nl to self -insure for WorkersCampen- u'ion, at provided for by section 37W of the labor Code. for dm performance of the work for which this permit is issued. ❑ 1 have end will maintain Work.h Compensation Insurance. as required by Section 37W of the labor Cade, for the perfomouce of the work for which this permit is issued. My Workers Compensation Insumoce carrier and Policy number am: Cartier: Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section reed not be comp le ted tribe permit is far one hundred dollars ($100) or less.) 1 certify that in doe performance of the work for which this permit u issued. I shall not employ any person in any manner an a to become subject to the Workers' Compensaton Laws of California. Date Applicant NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should become subject to the Worker's Compensation provisions of the labor Code, you most forthwith comply with such provisions or this permit hall W deemed revoked. CONSTRUCTION LENDING AGENCY I bereby.111. that there is a constnsctinn lending agency for the performan¢ u( be work for which this permit u issued (Sec. 3091, Co. Cd Lender's Nam. V Lender's Address 1 certify Nat 1 have rod this applicand n aria atom tar the above information is correct I agree to comply with all city and county ordinances and sate laws relating to building convection, and hereby authorlm representatives of this city to enter upon the shove- mepidgmu us,... for Impaction purposes (We) agree to cove, indemnify and keep humless be City of Cupertino against incomacque ec of thecasts ang expenseswhich may in any way accrue against said City Aeonseq of the granting of this permit. I,rT APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date SOURC REGULATIONS _ H , � _. Re -roofs igro m, tfAMlicanUCOmracwr tee HAZARDOUS MAJaERIALS DISCLOSURE Type of Roof Will the applicant err future building occupant store or handle hanNous material as defined by the Cupertino Municipal Code. Chapter 9.12. and be Health and Safety Me, section 25532(arl p Vos sA No All roofs shall be inspected prior to any roofing material being installed. Will the appBran, or future wilding occupant use egwpman, or devices which If a roof is installed without first obtaining an inspection, I agree to remove mil havardous air contaminants as defined by the Bay Area Air Quality Management Dissicll all new materials for inspection. ❑Yes No I have read the haaNnusmaerials rcquiemcnts under Capar6.95 of the Califon ni.Fk.IN &Safety Cod.,S 6. 25505 ,25533and25534.1undcuandtha,ilthc building does out cunemly have a WMML that it u my mspavihility, w notify the occupant of the require Best which muss be me, prior w issuvee of a Cerufina f OccuWm . Signature of Applicant Date c ` All roof coverings to be Class "B" or better tf tuner or authomad agent Dae r Community Development a ' f' 103300 Torre Avenue Cu ertino CA 95014 Telephone (408) 777 -3228 CITY OF Fax (408) 777 -3333 �UPEI�TINO Building Department r' JOB ADDRESS o Y I ai 2A A VC PERMIT # r� &D,6 Z,,, _/ OWNER'S NAME p PHONE , clO�-- y y6 -093 GENERAL CONTRACTOR: FAX # 6 -'V -56 e/- aS�l I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information- MOWN, r Owner/Cl 1'r Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile MOWN, r Owner/Cl 1'r Date (6f< CITY OF CUPEkTINO (♦ CITY OF CUPERTINO PERMIT APPLICATION FORM 6Z n '-'t (D s qPKPN # 3 Date: S-11,, Id q / Fee Group �z BAPPLOTHER OtherAppliances Building Address: Mailing Address (if different from building address): /JX1 ALfl4r,60 Ar pF]'LiItiO Bld Permits .foot Owner's Name: Phone #: L Civ6-o93s BBOILERI ie 01 0 Contractor: License #: MECHANICAL ND Ku) C. 5 BBOILER3 Boiler > 500K to 1M Btu Contact: Phone:6 -0-5-6 LI-0919 w Cupertino Business License #: BBOILER4 TF121 R0 Fax: 6S0 -56 Y- Js-&-1 MECHANICAL Building Permi Info: BM Btu Bldg ❑ Elect Plumb R Mech ❑ Job Description: WA-ft'cl2 ff1qhTKr/Z l't!°�-gc0tifrAT t-FSS UiN /T n Tax Residential Id Commercial ❑ Sq.Ft. Floor Area: $ /Sq.Ft.: BUILDING Cost of Project: a�oo 670 , Occupancy Gr p: CoQ Zone Type of Construction: Please check thl Ject is a BCONSTAXH otel second -sto addition: ❑ roject Size: Standard Laze ❑ Ma'or ❑ BCONSTAXR Quantity Fee ID Fee Description Fee Group BAPPLOTHER OtherAppliances MECHANICAL BBLDGFEE Bld Permits .foot BUILDING BBOILERI Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler > IOOK to 500K Btu MECHANICAL BBOILER3 Boiler > 500K to 1M Btu MECHANICAL BBOILER4 1.75 M Btu Boile=ZoneBUILDING MECHANICAL BBOILER5 BM Btu MECHANICAL BCONSTAX n Tax BUILDING BCONSTAX In/Quasi BUILDING BCONSTAXB CoQ Zone BUILDING BCONSTAXH otel BUILDING BCONSTAXR Constax - Resi/Mobile BUILDING BELEC1000 Elec 600V <= IOOOA ELECTRICAL BELEC1001 Elec 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING ZS SAS^ 1 of 3 07 �b ( l CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPEkTINO Quantity Fee ID Fee Description Fee Group BMISCELL Miscellaneous Fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BOVERTIME Inspection Overtime BUILDING . BPBACKFLOW Atmos heric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pb1g Fixture PLUMBING BPGAS Gas Piping System Fee PLUMBING BPINTERCEP Ind Waste Interceptor PLUMBING BPLANCHK Plan Check Fee BUILDING BPLANCKADD Plan Check Add Multi BUILDING BPLANCKREP Plan Check Repeat Fee BUILDING BPREPIPE Re i e Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn S rinkler/Backflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain & Vent PLUMBING BPWATER InstaWAlter Water Pie PLUMBING ATER Water Heater/Vent PLUMBING PWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit > 10,000 chn MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfin MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREM13USWAY Remodel Buswa s ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation ofFumace MECHANICAL BREMFURNOV RE urnace > l OK btu MECHANICAL BREMHEAT ater Installation MECHANICAL BREATMOOD llation of Hood MECHANICAL BREMMISC isc A aratus ELECTRICAL BREMNRAPP Ron -Res A liance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL 2 of 3 r� kC CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPEkTINO Quantity Fee ID Fee Description Fee Group BREMRESAPP Remodel Res Appliance ELECTRICAL BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL BREMTHEATR Theatrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Ins ection BUILDING BSW114 Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanical s . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Change BUILDING 3 of 3 E