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05040060�mZ Oo <5 n>Z ;yU Orn 00 sm� to fisc to I 0 z Z a>_ a� UC UC OF Ft. U2 i CI'T'Y OF CUPERTINO _ ,7� K ` ` PERMIT INFORMATION' - s BUILDING DIVISION .kCONTRACTOR +�,cbYw. .� f BUILDING ADDRESS: COOLS CUSTOM PERMIT NO. OSO40060 OW NEWS NAME: PERMIT ISSUE DATE ONE: SANITARY OL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED COKIRACTOR'S DECLARATION lb Description o I Wreby affirm that I am licensed under previsions of Chaplet 9 (commencing p with Section 70M) of Division 3 of the Business and Pmreasinns Code. and my license is in full forte and effect. O (6)LITS/220 CIRCUIT/COOK TOP/HOOD License Class IJc.a Dau T,� — N T T'S D r ARCHTIERS DEC I I 1 understand my plans shall W used u public < -;> C� Licensed Professional OWNER Bxempt fr DECLARATION 1 hereby Net I exempt from the Contractors License Law for dbe J Code: Any city or manly moo . Sect I. o following uasnn. Ronstr Business and 3 er it u improve. which requires a Permit to cnrtswm alar, improve. Jcmo1L h, or repair my strucmm & Wi prior to its issuance, also requires the applicant for such permit to file a signed statement is be Comracum's Llccnx Law (Chapter 9 Sq. Pt. Floor Area VdlUatlon that he licensed pursuan to the provisions of (commencing with Section 7000) of Division 3 of the Business and Professions Code) or 0 J\ Nat he is emmpi thetofrom and the basis for the alleged cmmpti.n. Any violation of 3 1VN1'bM*@r0 0 Occupancy Type Section 7031.5 by any applicant for a permitsubjecu the applicanuo Advil penahy of not mon Nan five hundred dollars ($5(10). ❑ I. Is owner ofthe property, O my cmploycer with wages u their sole compensation, Required Inspections will do the work. and thestuc,ure is notinunded oro@red for sale (Sec. 7614, Business and Promail Cade: The Contactors Lt.. law dors nod apply In an owner of property who Wildam improves thereon, and who does.such work himself car through his own employees, provided that such ireprovemmu are not intended oroRemd forsale. If. however, the building or improvement is old within one year of completion, the owner - builder will have the burden of proving that he did not Wild or improve for purpose of sal .). 1, as Owner of the property, am exclusively contracting with licensed contractors to construct tW project (Sec. 7034, Business and Professions Cade:) The Contractor's Li. cense law does not apply to in owner of property who Wilds or improves demon, and. who contracts for such pmjecu with a contexmr(s) licensed pursuant to Ute Contractors License Law. ❑ l am exempt under Sec. ,B& P C for this reason Owner Dare WORKER'S COMPENSATION DECLARATION 1 hereby of urn under penalty of perjury We of the fallowing declarations: 1 have and will maintain a Cenificum of Consent On self-insum for Workers Compen- sation, as provided for by Section 37M of the Labor Code, for the performance of the work for which this permit is issued. ❑ I hors and will maintain Workers Compensation Insurance, Is mquirtd by Sccu.n 3700.1 the La W, Code. for the perf.reancc of the work for which this permit is lssuni My Workers Com ounce anis and Policy nY�Oabter%arc:% —//0 CardCar. Pe iry No.: a c'. IFICATE OF EXEMPTION FROM WORKERS' Ae Q JCOMPENSATIONINSURANCE (This sectiw mmd not W c.mpleud if the permit is Intone hundred dollars (SIM) or less.) I certify that in the performance of the work for which this Permit is issued. I shall not employ any person in any manner so az to become subject o the Workeri Compensation Laws of California. Dau Applicant NOTICE TO APPLICANT: IL after making this Cedifcale of Exemption, you should become subject In the Worker's Compensation provisions of the Labor Crom, you mum forthwith comply with such provisions or this Permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY 1 thereby u then is a construction 30lending agency for the Performance of the work for which Be.thipermit u issued (Sec. 3W7, Civ. C.) which Lender's Name lender's Address j I certify that 1 have read this application and walk Nat me aWvc information is ' ' comet. I agree to comply with all city and county.Nideams and sum laws totaling to building construction. and hereby aulhodm representatives of this city to enter upon me above mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against j liabilities judgments, costs and expenus which may in any way acerae against saidCity in consequence of thc granting of this permit. ' APPLICANT U STAN.B-W 17COMPLY WITH ALL NON -POINT Issued by:9 Date SOUR�,AE,. 1 Re -roofs Type of Roof Si m o plicanVCon0azr Dow HAZARDOUS Will the applicant or future Wilding median, sham or handle hrrardous mmonal as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety Cale. Sebonu.n 25532(a)7 All roofs shall be inspected prior to any roofing material being installed. ❑ ❑No If a roof is installed without first obtaining an inspection, I agree to remove Will th. applicant s mare building occdpam use eq.ipmm, or devices which mit hates ous air contaminants ax defined by the Bay Area Air Quality Management all new materials for inspection. Dimict7 ❑Yes ❑Nd Hit mad be ha ardousmawrials requirements under Chapter 6.95 of the Colifm- niaHealth & Safmy CWd , Sceuons 25505.25533 and25534.l undcrsund Nm if the Wilding does not currently have a tenant. that it is my, reapauibility u notily sbe.ccdPant of the degmreme- poortaissuanceoraCcrificateofOccupancy. Signature of Applicant Date roof coverings to be Class "B" or better O tiro sedasent Date CITY 0f �UPEkTINO V/ X63 Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Building Department JOB ADDRESS: 101 0 , 1316A4 eY / PERMIT #�; b OWNER'S NAME: 7,F7po PHONE # GENERAL CONTRACTOR: i-AtlGop FAX # I am not using any subcontractors:. Signature Date Please check applicable subcontractors and complete the following information: 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 Date CITY OF CUPEkTINO CITY OF CUPERTINO _ PERMIT APPLICATION FORM S " ' 0 APN # Date: Fee Group BAPPLOTHER Building Address: Mailing Address (if different from building address): Owner's Name: Phone #: Contractor: License #:�`�� Contact: Phone: gz7fr- 35'3 j6yZ Cupertino Business License#: rin7 Fax: BBOILER3 Building Permit Info: Bldg ❑ Elect IQ Plumb ❑ Mech ❑ Job Description: J -All t l (6 -4 bn/ 220 6 ilG Gal ivC4i Residential ❑/$vMe !°(e ,�i�/ 71v Sf�I/ .Vel-- Co° 7� 04gcmmercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Projects O O� Occupancy Group: Type of Construction: Please check this box if the project is a Construction Tax second-sto addition: El Size: Standard ElLarge El Major ❑ Ind/Off/Comm/Quasi Quantity Fee ID , Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler> I OOK to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to 1M Btu MECHANICAL BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL BBOILER5 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 <= 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 W 1 of 3 4 r Sifizz CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPERTINO uanti 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 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 BREKkULHAN 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 Fumace > 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 2 of 3 C rr of CI IPFRTIIV('l CITY OF CUPERTINO PERMIT APPLICATION FORM --I .`. I— 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 Insection 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 Chane BUILDING 3 of 3