05020174 CITY OF CUPERTINOR
BUILDING DIVISION PERMIT VCONUACTORINFORMATION
BUILDING ADDRESS: CUPERTINO PLUMBING PERMITNO)5 02 0174
OWNER'S NAME: PERMIT I4UE DATE
DANIEL SO 10297 S DR ANZA RT17 119 251200c;
ONE: SANITARY NO. CONTROL NO.
(408) 253-0618
ARCHITECrIENGWEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uoo LICENSED CONTRACTOR'S DECLARATION O O O
FCI hereby affirm Net I am limwd under proviuons of Chaper 9(commencing Job Description
iW with Scction]it if fDivivan 3af NC Busnw and Rofcasuns Code.andmylicuvc is
y
in full force and if a. REPIPE & WATER SERVICE
Liccnx Class Lie,.m
�— Dale Conuacmr
"J ARC all Im used
public
LAR
w U I undemanJ my plans shall be uud a puMie reem. 'r /
n n
W Lkcnud Professional 4'p
i05
OWNER-BUILDER DECLARATION U�
.� f 1 hereby affirm that I am exempt from be Contractors Lmmoua Law for the
O O following mason.(Section RD L5,Business and Profesaioes Code:Any city Or county
ym which requires a permit to construct.alter,improve,demolish,or repair any atrumuu
r i y prior in its issuance.also mquims the applicant for such permit w Ole a signed su amen ay
< that he is licensed pursoanitothcprevision orducCanuacxr'sUccnuLaw(Chapuf9 Sq.Ft. Floor Area Ualuatibn
or (cammmming with Suction70M)of Division 3 ofthe Busitmeaand Proressions Code)or
wRthat he is exempt demfrom and Ne bats for the alleged exemption.My violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 6AMIG&VaelO 0 Occupancy Type
not mart Nan five hundred dollars(8500). P Y YP
0 L as owner of on,pmpmry,in my employs with wages as their x4 compensation,
will do the work,and Ne swaum is not intended or offend for sale(Sec.7044,Business
and Proressom Code:The Convector's Littre Law dao not apply to an Owner of, Required Inspections _
propenywhei Wilds or inflows,themon.and who doessuch walk himselfordtrough his
own empinyace.provided Nat such improvements are not intended oroRered forale.If.
however,the building or improvement is sold within ane yeti of completion,the owes,
builder will have the Wdcn of proving that W did Out Wild in improve fat purpose of
.is I.
0 1,as Owner of the property,am exclusively contracting with licemed!contractors to
construct the pmjca(Sec.7014,Business and Professions Code:)Tho Contractor's Li-
cense law does not apply to an owner of property who Wilds or improves thereon,and
who contracts for such pmjcm with a conv'xmr(s)licensed putuant to due Convacsofs
License law.
0 1 em exempt under Sec. .B&P C for this mason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following dalararions:
41 rl 1 have and will maintain a Ccnificam of Consenuo self-itaum for Workers Campcn-
smon,as provided for by Sccuon 3700 of the Ia mr Code.for the perfonmance of the
work for which this permit is issued.
0 1 have and will maintain Worker's Compensation Irsumec,u required by Section
3700 of Ne Inbar Code,for the performance of Ne work for which this permit is issued.
MyW.,Ixes.CCconomatoomImInsuramea causer and Policy�mb�aJe:.-,_'LU `
Cartier. � Policy No.: t ((...OZ.S' _1e .
CERTIFlC O OF SATIONIONFROM EORKERS'
COMPENSATION INSURANCE ,
mussemion recd not becompleed if rhe permit is farone hundred dollars(SIM)
less.)
1 certify that in Oc performance of de,work for which this permit is issued.I shall not
employ any person in any manner an as w become subject to one Workma''Compere uien
Laws re
of California.Da
Applicant
NOTICE TO APPLICANT:If,after making this Certificate,of Exemption,you should
become subject to the Workers Compensation provisions of the Leber Code.you most
.J,Z foMwidi comply with inch pfnvalms or this pi shall W dcemed uvokcd.
zO CONSTRUCTION LENDING AGENCY
ti
F 1 Wmb affirm that Neu is a construction lending lm the performance of
a 7 the nder's a which Nu permit is issued lsea.109],Civ.C.)
M a Lender's Name,
6. Lcndcis Adduss
Z) Z
V Q 1 certify that 1 have read this city
and c un and imar that the above information is
Ly U cored 1 ague to comply with all city and county ndinan es and sou laws relating e
fit) abOw-gconstsuction.and hereby anNonacreprescnutircs of this city in closer upon de,
Y'a shove (We)agree
to saw.
for inspection
mnify an keep s.
ha
(We,)agree to saw,indcmnifY and keep harmless the City of Cupertino against
F'N Iiabillticsjudgments.cosies and expenses which may in any way accrue against aid City
C)Z in consequence of Ne granting of this permit.
'—' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC
2-2-5 C5 Re-roofs
Si of pitactor Date
f AZARDOUS MATERIALS DISCLOSURE Type of Roof
Will she applicant or forum building nccupem nom m handle hvatdous material
u defined by 1W Cupertino Municipal Cock.Chapter 9.12.and the Health and Safety
code. C'mi zs63z(a)? All roofs shall be inspected prior to an roofing material beim
❑Yea ONO P P Y g g installed.
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or fuwu building occuWnt esu equipment or devices which g
mit hanNnux vii Imiumi
on
as dcuncd by Ne Bay Area Air Quality Management all new materials for inspection.
DiWit
❑Yes ONO
1 have read the hvardousmatenals uquimments under Chapter6.95 of the Gliron
ria Hcslth&Safety Code,Sccuom25505,25533mdn534.lundenta ifNc Wilding
does not currently have a aman4 that it ism reapomihiI ty to noufy,the Occupant of the
re nm which ria cof.Cceoro'copancy. Signature of Applicant Date
Owner or oat age <2 Dae All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
�
CITY OF Fax(408)777-3333 UPEkTINO
Building De artment
JOB ADDRESS: /USS / PERMIT # OST 2-0 ) 71-/0 ) 7L
OWNER'S NAME: Q JPHONE # Sj l
GENERAL CONTRACTOR n FAX # s
I am not using any subcontractors: 1 U 5
Signa Date
Please check applicable subcontractors com Tete the following information:
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 f I
Roofing
Septic Tank
Sheet Metal
Sheet
T' e
Owner/Con ac or S- ature Date
CITY OF CUPERTINO
CUP TOFF
YINo PERMIT APPLICATION FORM OS 7V
N # _ j ' .O(qb Date:
Buildin- Address: l Mailing Address (if different from building address):
e .
O er's Name- Phone #:
0/, b�C/
/
Co tractor: License#:
p •� IhG . LoZ�-I �US�
Contact: I a Phone: 2 O(�1 g Cupertino Business License#:
Fax: 253 O LP! �–
Building Permit Info:
Bid �N Elect Plumb Mech ❑
Job Descripti—on/ m
pp - ' �J 6 GY
Residential fI� Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: Occupancy Group:
Type of Construction: Please check this box if the project is a
second-story addition:
ro'ect Size: Standard ❑ Large ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boileff> 500K to I Btu MECHANICAL
BBOILER4 Boiler:> 1M to 1.75 M Btu MECHANICAL
BBOILER5 Bailer> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX In&Off/COmm/ uasi 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
ldlbk BINVESTIGA Investigation fee BUILDING
2 � 7 � Fs
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°7,
r- ' 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 Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
t 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/Bain 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 cfm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREWIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace 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
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( � CITY OF CUPERTINO
CITY of PERMIT APPLICATION FORM
CUPEkTINO
Quantity Fee ID Fee Description Fee Group
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 Inspection BUILDING
BSWIM 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
PLLONGRNGC Planning LR Comme/Multi-Fam PLANNING
PLLONGRNGR Planning Long Range Residential PLANNING
ZADDCHG Address Change BUILDING
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