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04030022CITY OFCUPERTINO BUILDING DIVISION PERMIT _ €COL�ILRACTOR�INFORMATIQN BUILDING ADDRESS: JERRY SIMMONS ELECTRICAL PERMTr NOD4030022 OWNER'S NAME: PERMIT ISSUE DATE DAVID402 DNE: '/2004 SANITARY NO. CONTROL NO. (408)371-1393 ARCHITECT/ GINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 LICENSED CONTRACTOR'S DECLARATION o Job Description 1 hereby affirm that 1 am licensed under Pmvisou of Chapter 9 (commencing with'on] )ofDiviso 3ofthe Businessmud ProfessionsCode.mlmylicense is mfaun derrretC-moo Lk 2YF Lice C ag UPGRADE (E) WIRING FIN a6-4 AM Co�yn�veEnpor I understand my plans sNlll be sod iipub c cut MAR 1 5 2004 Licensed Prorcssmand OWNER -BUILDER DECLARATION 1 hereby M. Law for Ibe 11. casmpt from Ibo Cocoons BUILDING Code: Any c county following soon. on RI31.5, Business and Prafeuio s Code: Any city (ie s whim Permit t atter, W sig Any suumum . Pmmio re cores n its issuance. Me for res hdemolish.Pero a Pdormitsiensedprsu requires Me applicant of for such Pcnni'nicens, Lawned (Chapter the Contractor's nx �w(eMpmr9 thmbeisfnnxd wrxammthe pm.ivision Sq. FL Floor Area Valuation and 3 NC Business arta Prurcu vi Code) or ]000) of Division r f I Net M u exempt thes(rom nd Nc buil for tis staged Gumption. My violation of that M is examWiththerefrom the Si noo APN Number Occupancy T P y yPe Session 703M by any Applicant for a permit subjects the applicam to a civil penalty of Act mart Nan firs hundred dollen (S50)). .. ❑ I, As ownu of lbo Property. ME my coop].,= with wages As does sok compenullon. will do the work And Ne.nature is not intended or offend for We (Sec. 70". Business Required Inspections and Pmfessiou Code: The ConmcmYs License law does not apply be an sweater of property who builds or improaes thereon, and who Fees such work himself or through his own employees, provided Nal such improvements are not indeed an named for We. If, however. Ne building or improvement is sold within one year of completion, the owner - builder will have the burden or proving that W did not build or impmw fw purpose of We.). ❑ 1, as owner of the property, am escluivcly contracting with licensed canoanort to coutmct the pmjm (Sec. 7014. Business and Professions Code:) The Contra urr't U. ¢tie Law dots oat apply to an owner of property who Wilda or improves thereon, and who contracts for such projects with a envxtot(s) licensed pursuant to the Consracmts Igcrnse Law. 1 am esempt under Sec. . B & P C for this reason ' Owner Date WORKERS COMPENSATION DECLARATION 1 hereby affirm under pntally of perjury cam of the fallowing declarations: I hale and will maintain a Certificate Of Consent to self -insure for Worker'sCompeer- cation, as provided for by Section 3700 of the Labor Code, for the Performance of the wwk for which this permit is issued. Cl 1 have And will maintain Workers Compensation Iuurence. as squired by Section 3700 of the labor Code, for the pertormmee of the work for which Nis permit is issued. ' My Worker's Compensation Insurance carrier and Policy number are: Carrier. Policy No.: _ CERTIFICATE OF EKEMMON FROM WORKERS' COMPENSATION INSURANCE ' Crels senln need notbeeomplewd if the Permit is rmow hundred dollars (SIM) m less.) 1 certify the in th perfnrmmcc of the work ror whirs Nis Pcrtnit u ;rimed, I shsl out a employ any pc inanymnnc Ps t be a ubj<n Worked ComPensulon Laws efC ice. DnN ) MNLCAM _ IpTICE TO UC NT: If, after making this Ccnifieate of Exemption, you should sash' n w the Vorkeb Compcmation provisions or Ne Labor CMc, you mum fnMwtth Comply with such provisions or this Permit shall x deemed revoked. CONSTRUCTION LENDING AGENCY I Wrobyaffirm that then its cottsvuction lending agency for lW perfurmn¢ of the work for which this permit is issued (Sce. 7097, Co. C.1 ndName LccYa Lender; Md. Adddress I certify that 1 have rend this application And suss that the above information is C� COME, I agree 0 comply with all city and county oolinamaa and state laws miming to building construction. and hereby amhoriu representatives of this city to onto upon dss above-menud g4 propcny fora inspection e% whicoscs. (We) acme m uvc, indemnify and keep harmless the City of Cupcnino againstflabil may in my way soneAgainst said City incoitics.jnec, of cgrouandof thisleswhim in consequence of the graining of this Permit. APPLICANT UND RSTANDS AND WILL COMPLY WITH ALL NOWPOINT Issued by: Date SO CE REGUONS. Re -roofs azure f Applicalu Conmcmr a HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or funs Wilding Occupant atom or handle Itassmous material u defined by the Cupertino Municipal Code, Chapter 9.13, and thAnd Health d Safety oda. Sn:Ye255320)?❑Yea I<�Na All roofs shall be inspected prior to any roofing material being installed. Will the, Applicant or future building arras tut axe PP 6 W equipment or devices which If a roof is installed without first obtainingan inspection, I agree to remove PO .mit hevardnus air cammninnu u defined by the Bay Arca Air Quality Management all new materials for inspection. Disoiet? ❑Yes J �Nu I have read the Waaofousmassrols requirements under ChaPer6.95 of the CAiron ma Health &SafctyCedc. Sceumu]5505.25533 ad 25534.1 texcestand thatiftbe Wilding dw not currently he.0 a ee L Nm it is my rtspo ihility m notify the occupant or the requi ntswhmnmam mnpoortoiesamaanra a or raPneY. Signature of Applicant Date �' All roof coverings to be Class "B" or better rnm vW agent Date MF �UPEkTINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Building Department JOB ADDRES§/ PERMIT # 0 02Mol, ✓/ OWNER'S N PHON ld : V - GENERAL CONTRACTOR: FAX # 1 — OU 3 I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information 5 Z, k�, Owner/ Contractor Signature 3 ate 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 5 Z, k�, Owner/ Contractor Signature 3 ate - CITY OF CUPERTINO CITY Or PERMIT APPLICATION FORM CUPEkTINO Ak e-) Wi APN # 0 Date: 3 % BAPPLOTHER Other Appliances � a. BBLDGFEE B ilding Address: Mailing Addr s i ifferent from building address): BUILDING 3 Boiler <= 100,000 Btu Own is Name:Phone #: BBOILER2 �n MECHANICAL Con ractor: License #: Boiler> 500K to 1M Btu Jrzfav/^n stn i eco BBOILER4 Contact: Phone: AIQ --371—/3 Cupertino Business License#: MECHANICAL Fax: qal- 1- OG 2 3 /Ll Boiler> 1.75M Btu uil 'ng Permit Info: BCONSTAX Bldg ❑ Zlect Plft ❑ Mec ❑ BUILDING Job Descn : fm Ind/Off/Comm/Quasi Residenti Commercial ❑ BCONSTAXBQ Sq.Ft. Floor Area: $/Sq.Ft.: BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Cost of Project: / Occupancy Group / BELEC1000 Type of Construction:Please check this box if the project is a BELEC1001 Elec 600V > 1000A second -story addition: ❑ w Quantity Fee ID Fee Descri tion Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILERI Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler > 100K to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to 1M Btu MECHANICAL BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL BBOILERS Boiler> 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Comm/Quasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax — Resi/Mobile BUILDING BELEC1000 Elec 600V <= 1000A ELECTRICAL BELEC1001 Elec 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY —Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING 1 of 3 alt I CITY OF CUPERTINO CU CITY0 NO PERMIT APPLICATION FORM 2 of 3 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 rinkler/Backflo 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 cfm MECHANICAL BREMAIRHAN A/C Units <=10,000 cfln MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Ligliting Fixtures ELECTRICAL BREMFURN Relocation of Fumace MECHANICAL BREMFURNOV Relo Fumace > I OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc A aratus ELECTRICAL BREMNRAPP Rem Non -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 BRENMPALT R air/Alter Heatin MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Mar uee ELECTRICAL 2 of 3 (^% CITY OF CUPERTINO On OF PERMIT APPLICATION FORM CUPEII;TINO Quantity Fee ID Fee Description Fee Group BREMTHEATR Theatrical Ligbting 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 Inspection BUILDING BSWIIvI 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 Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING .J • 3 of 3