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04020103 CITY OF CUPERTINO ^`' �1,1w ' ''� '`` '1" BUILDING DIVISION PERMIT ,,gONTRACTORINFORMATION- e s sets ,A=�.i~.x 3'1 ssr;. BUILDING ADDRESS: PERMIT N 4020103 NER'S AM : PERMIT ISSUE DATE ONE: SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG EfECf PLUMB MECH LOO LICENSED CONIAACTOWS DECLARATION O O O O I hereby affirm that 1 and liamed under provisions of Chapter 9(commencing Job Description itu$ado 7QT0)ef Divmon 3ofthellusincii Profmidom Code,andmylimanatis in fall to ea° lffl� MAIN ELECT SERIVE PANEL CHANGE j q= L... D Lic.« WeDam ARCHf1ECTS D"EclJtF3 CONTRACTOR: ELECTRICAL POWER SERVICES I unEcrsund my p ns shall W used as public mcnrtls R.[I 30 Licensed Professional 5 OWNER-BUILDER DECLARATION I 1 hereby aRum that I am cramp(form the Contractors License Law for the 00 following remora(Section 703 1.5,Business and Professions Cade:Any city or county $ which requires a fermis to common,alter,Improw,demolish,or repair any smMurc Fqiy poor in its issuance.also mquims sheapplicant for such permit in Man sigmdv.mmem d U that he is licensed pursuant to the provisions of the Conracmr's Liaise Law(Chapter 9 Sq.Ft. Floor Area ValuatiV900 (commen ing with Section 70011)of Divided 3 of the B miners and profession,Code)or 7 e g$_ Net he u exempt shemfsmn and the bmu for the alleged computed.My violation of Section 7031.5 by any applicant fora permit subjects the applicant to a civil penalty of APN Number Occupancy e not more than BK hundred dollars(SSW). P Y TyP ❑I,esownv ofthe proprny.mmy moployw with wage ssthe'v sok cpmpenssdon, 37527042 . 00 will do the work and the awmum is not intended or offered for sok(Sec.71 Business n W and Professimu Code:The canuazlers Lime law dao net apply to an owner of Required Inspectio rFI N�t LD-® propery.holm ids or improver thereon,mi doeisuch work himselforduoughhis as own employ=,provided that such imprmemenu are not iemMed proffered formic.if, however.the building or improwment is sold within one year ofcompiedon.the oe owner- MAR gT 7 1 L.5004 Willer will hthe burden of proprov proving that he did not build or volume for puryo a of M sok.). I,as owner of the property,am exclusively contracting with licvued convectors m ,® �0 cconstructladao ct the prejev(Sec.7044.Business sad Prefesdem Code:)The Common's Li- �yBUILDINGN1tl� « e w not apply m an owner of property who h tilds or improves daemon.and who customer for such projects with a eenvacmKs)liaised pursuant o the Contractors Lkcnse Ls- 0 l am cramps under see. ,B B P C for this rcuon Owner Dau WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury me of the following doclarviom: I hale and will marble a CeniGnu of Consent to self-insure for Wmkets Cori on,m provided for by Simon.37M of the labor Code,for the pedarmarce of dm work for which this permit is issued. ❑1 ban and will main0ln Wolkcri Compensation Imuran:,as inquired by Section 37W of the labor Code,for do performance of dm wink for which this permit is issued My W :ch Compensation I x rota nrrier and Pyiey member.: YT/0.:00/O O CERTIFICATE FEKEM1MON FROM WORKE S' COMPENSATION INSURANCE (Th0 section need net beeompleted If the permit is for one hundred dollars(SI W) or k s) 1 certify that in the performance of the work for which Nis permit is issued,I shall nus employ any person in any manrmrm as to become subject to 1M Workers Commission Laws of California.Dau Applicant NOTICE TO APPLICANT:If,after making this Cortificam of Exemption,you should become subject to the Worries,',Compensation provisions of the Lour Code.you mum .,O fuMwith amply with such provisions or this permit shall be deemed rewkcd. z'"-' mou d rRUCf10N acm.le G AGENCY \\ E w i 1 hereby aRmn But throe UCTION LEN lending aboneyAGENCY for the pcnformarra of !X the work fur which this permit is issued(Sec.3W7.Civ.C.) it)0 Lender's Name z Lender's Address U 0 1 anify that I have road this application and sum that the show information is Fcorrect.I agree to comply with all city and county ordinances end sum laws misting to 0 U building construction.and hereby atimmim representatives of Nis city m enter often dm ��1\ a billmomioned property for inspection purposes 'O F 4 (We):gra m mw,indemnify and keep handless the City of Cupertino againIl fq IiabBiues.jud mWthesmit. may in anywayaccrue against saidCity U z i3 eo rte rmit.SPPL E GWILL COMPLY WITH ALL NON-POINT Issued by: D e 1 Re-roofs Si uo p unVCo HA RDOUS MATERIALS DISCLOSURE I Type Of Roof Will the applicam or f num building occupant mom er handle hanrdous omicnal as defined by the Cupertino Municipal CoOe.Chapter 9.12.and the Health and Safety "doCods,Section 25532(a)? ❑Yea 4n� All roofs shall be inspected prior to any roofing material being installed. Will be applicant or future building occupant um equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove it hazardous air comaminamx m d fined by the Bay Arca Air Quality Management all new materials for inspection. L Nu e hmardnus materials mquimmcmsundor Clupur 6.95rideC;ihRr- oh, ats255053am12553a.1un4rauMthmifthe WiiJing w a ane Ne ' responsibility m noti the upon(ofthe at et or anapfVrdi sap ey. Signature of Applicant Date oge l/ D All roof coverings to be Class"B"or better Community Development 10300 Torre Avenue t Cupertino CA 95014 Telephone(408)777-3228 CITU OF Fax(408)777-3333 it PEf�TINO Buildin De artment JOB ADDRESS-,2 /87l,D *4*1WA��b1� PERMIT # OWNER'S NAME: ' Hsi PHO # �g moi! v� GENERAL CONTRACTO •� /acd(�Buil! u)�2. FAX #" I am not using any subcontractors: / Sign e Date Please check aoplicable subcontractors and complete the followinginformation: 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 e O L��— caner/Con for Signature � Date 10/28/03 ((///{ CITY OF CUPERTINO =, gLzz CITY OF PERMIT APPLICATION FORM CUPEkTINO Quantity Fee ID Fee Description Fee Group BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BOVERTIME Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE -Bldg Permit Fees BUILDING BPFIXTURE Pblg 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 rinklerBackflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain &Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfrn MECHANICAL BREMAERHAN A/C Units<= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Fumace MECHANICAL BREMFURNOV Relo Furnace> l OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non-Res Appliance 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 BREMRESAPP Remodel Res Appliance ELECTRICAL BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL 2 of 3 CITY OF CUPERTINO I CITY OF PERMIT APPLICATION FORM CUPEkTINO Quantity Fee ID Fee Description Fee Group BREMTHEATR Theatrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific Plan BUILDING 1 BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Insection BUILDING BSWM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Ternp Dist Svcs ELECTRICAL BUSLIC Mfoot s License BUILDING ELECTRIC l s foot ELECTRICAL EPERMITFEE it Issuance ELECTRICAL MPERMFEE al s .foot MECHANICAL MPERMITFEE it Issuance MECHANICAL PPERMITFEE ermit Issue PLUMBING PPLBG Fees foot PLUMBING ZADDCHG s Chan e BUILDING • 3 of 3 1D � CC. CITY OF CUPERTINO CUP TYOF O PERMIT APPLICATION FORM JWLPN# ? / .Z v K -�_ Date: __/�/t J/ J CJJ b Building AddressAQP Mailing Address (if different from building address): I Owner's Name: (�� Phone#: qO0� 7,V77 �(2� Contractor•: License #: i - Contact/' Phone: Cupertino Business License#: Fax: Building Permit Info: Bld El ❑ Plumb ❑ Mech ❑ Jobescription: � ResidentialCommercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: r� Cost of Project: Occupancy Group: Type of Constructio Please check this box if the project is a second-sto addition: ❑ Q--uantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILERI Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> I OOK to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to 1 M Btu MECHANICAL BBOILER4 Boiler> 1M to 1.75 M Btu =BUILDING BBOILERS Boiler> 1.75MBtu BCONSTAX Construction Tax BCONSTAX Ind/Off/Comm/ uasi BCONSTAXBQ Con. Tax for BQ Zone BCONSTAXH Hotel and Motel BCONSTAXR Constax-Resi/Mobile BUILDING BELEC1000 Elec 600V <_ IOOOA ELECTRICAL BELEC1001 Elec 600V> IOOOA ELECTRICAL BELEC200 Elec Svcs 600V<= 200A ELECTRICAL BENERGYEner BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING 1 of 3 2,X. 7-3