04030238 CITY OF CUPERTINO
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BUILDING DIVISION PERMITCI®NTRAC�'T®RRM
NFOATION
BUILDING ADDRESS: PERMIT NO.
CUPERTINO PLUMBING 04030238
ER'S NAME: PERMIT f55UE DATE
PHONE: SANUARY OL N0.
ARCHITECTIENGINEER: BUILDING PERMIT INFO _
BLDG ELECT PLUMB MEC"
uOp LICENSED CONTRACTOR'S DECLARATION -
m 1 Mm fmby Arlon than I aeared under Bovine"of asp=9(commencing Job Description
i withScnion]ofq)afDivision3ofthe tininess And Professions Code.andmylmenuia pip g�
$iin mu(nhescand c / G G2N 4a? BATHRM REMODEL ��®�ryi1��'®
Liccnu Clan
Z;:p Dao: Contractor
'�''C Lv mcnuId uPnrrclrefcssiodnanllY laAnRa CHI EkSOLARATION
all(LPublic mends
MAY 20 2004
a3 Oat I am exempt f DECLARATION BUILDING
0 I herohy.(M.S. that 11. exempt from tW Contractor's Co License law for the BYa 11AVg
o O following..on. emit t ](131.5.Business and Profeainm Codr:Any city or mew
$ which requiresm c,Alan re cores ft alms rat for sat fiendish,ri repair ed ommon,
FZy Pnmmits iauanee.dm requires the applicant for such permitm fileasigned sutemenl
ppss< that he is licensed pursuant Sq.F[. Floor Area Valu hon
ttm
ml-$ (commencing with Swann 7")of Division]of she Business and Professions Code)or
than he b wmpt therefrom and the basis for the Alleged exempdon Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of 3I11' pgyberp p Occupancy Type
net mom than five hundred dollars(SSW).
l,uawnerof Nepsopmy,amyemployccswiNwgesudseamlcc mmoon,
will do Ne work,end the smtctum is nal intended or offered footle(Sec.7044,Business
and Professions Cade:The Conaumra License Law does not Appy to An owner of Required Inspections
P.,ny.W buil&«improseadmeon.mdwhod=swhwmkhimWforw ughhis
own employees,provided that such improvements art not intended moffened(orale.If,
however.Ne building or improvement is sold within one ycur of compledon,Ne owner-
builder will hoe the burden of proving that he did our bold or improve for purpose of .
ale.).
1,as owner of the propcny,am aselusively contracting with licensed contractors In
comuuct the project(Sec.70a,Business and Professions Code:)M Conaumr's Ll-
ecme law dors not apply in an owner of property who builds in improv dtemon,And,
who contracts for such poijecte with a con int licensed pursuant no the Conumme,
License Law.
lamacmptunder Sec .B&PCfmthisrramn
er Data
WORKER'S COMPENSATION DECLARATION
I hereby aRom under penalty of perjury aro of the following declaration-
0 1 haw and will maintain a Cerufiam of Comm to self-insure forWor sCompen-
auon.As provided for by Setian 37W of the labor Code.fm the perfmanana of the
work for which this permit is issued.
❑1 haw And will mainuln Worker's Compensation I.ce,As remained by Section
37W of me labor Cade,for Ne performance,of the work for which this permit is issued.
My Wtulmli Competuauon lm ttcartiu and Policy number Arm
a erg lacy No.: g
CERTIFlCCOMPENS ATE OFE) ()N MOM E ON INS RA C6 WORKERS'
(This section need not becompteted if t e permit Is formic hundred dollars(SIM)
or less)
1 certify that in the parfsumence of the work for which this permit u issued,I shall not
employ any person in any manner an as to become subject to the Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.After making this Cci ificate of Exemption,you should
technic subject m the Worker's Compensation provisions of the Labor Code,you mum
0 O foMwith mmPly with such provisions Or thio mm
Permit shall be dooed wked.
Z�' CONSTRUCTION LENDING AGENCY
'r. ► ihcmhy attire that Nem is.construction lending agenpq far the Per(urmentt of
a the wart fm which Nu permit is issued(Sec.3097,CO.C.)
QLendees Nurse
=z Lender's Addmas
C) 1 ttnee than 1 have mad Nis City
and c un and sura Nas the above information is
0 building 1 agree to comply with all city and county ordinances and some laws r upon
m
V buive-menvwairoend hembyauthonsmPmanmiv ardor ciymcnter upon tha
W
above-mentioned property for imnify an purposeDate'G
(We)agree to saw,indemnify end kith harmless w City mCupertino against
N inar sempoe judgments.emuand Ofpemeseart. they in Any way creme agaimtsed City
U z A APPLICANT
UNDERST$OahtANDS
of Nu D WILL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SOURCE,g��GULATIONS/ / � -
(/�"1...v� -3"2 L-O Re-roofs
lien ofAppucant,Contranor Data
HAZARDOUS MATERIALS DISCLOSUR Type of Roof
Will the applicant or fulm a building occupant nom orhandk heardous mammal
As defend by the Cupertino Municipal Code Chapter 9.12,and the Health And Safety
e, FI
iss32(a)7 `� All roofs shall be inspected prior to any roofing material being installed.
❑Veno
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
7m4uLmosentar
t baardnus air contaminants u defined by du Bay Area Air Quality Management all new materials for inspection.
rict?
❑Yes }9Nu
1hatsmWtheh7a w/s`numrialsmquimmenaunderC pter6.95oftheCsii(or-
Hca)@SefetyCo .S.6.25M5.25533.d25534.1.nk.rsm airNc Wilding
not currently have a urine Nat it is my mspausihiliy m noufy the occupant of the
which nun t aancc ter,eenifimm rOeeupaey. Signature of Applicant Date
Owner m. Nonmdegam _ZGDate All roof coverings to be Class"B"or better
CITY OF CUPERTINOV,
BUILDING DIVISION PERM* FORMA ,NN
BUILDING ADDRESS: PERMITN0.
CUPERTINO PLUMBING 04030238 '
OWNER'S NAME: PERMIT ISSUE DATE
ONE:
SANITARY OL N0.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
ski O o LICENSED CONTRACTOR'S DECLARATION p. -
YeF 1im70affirm Nat1am licensedBuinssprovisionsof,Code.and
IOb � 1p s� LE
<Z art with gr.Elion]IXMD of Divixion3of Nc��sm��cv and Profcssianx Codc.and myliccnsc is y9r`� //Y/app®��
5qi UmmseoClasan° `L- G .L�e.. GZy 9oT BATHRM REMODEL
Dam Contractor
IsAidl A0.CHTIECTSDCLA0.AT10N
1 undo nJ NY lana s all M1gauM ax pabbc rtanrJa MAY 7.0 2004
w
3 o to Licensedd Pmfcsxinnal ' 1 �■®\��
3 OWNER-BUILDER DECLARATION BUIL"'
M�
<2 1 hereby vdjna that I em Attempt from the Cmans r'e License Law for the !P!!//v .
p O following mason.(Saito]1131.5,Business and Arrows.
de aas h.or:Any city stricture county
x 9 which requites n Permit re c�res the,almG applicant
for such
demolish,or repair any ned statement
f Zi I AAAA
pat heir issuamaalso
ntto the Novisios of the for Contrator's imnserile a aw(Chmmcm
A, NommencanmdPmwao7")ofDivisionoftheBnneAsAiansclaw(Cheptcr9 Sq.F[. Floor Area Valu [Ion
rc� (commencing with Scaion)l%10)of Division]of the Businssand Professions Go�C)ar
i $
that he is exempt NAmfrom and the basis for Ne alleged...pd.Any violation of
section]831.5 by a"applicant for a permit subjects Nc applicant to a civil penalty of 3.ArD).i.#T....A.er00 Occupancy Type
not more than Eve hundred dollars(55881. OWNAbl�W
❑I,Air owncr of,hA Property,Anmy.mPloy..with wag.As theb sole compensation,
will do the work and the swnum isnot immndcd mmirer 1 W.Ale(Ser.7614.Btsirv`•
And Professions ewe:The Contractor's Liatue Law doss not apply to an owner of Required Inspections
property who faults orimproves Nerenn,and who doessuch workhimaelf ortheugh his
awn emplayas,provided Nat such impmwme"B Am not intended oroR.cd for Asia.If. .
however,the building or improvement is sold within one year of compleAon,the owner.
Wilder will have Ne burden of proving that M did not build or improve for purpose of
sale.).
❑1.as owner of the property,am exclusively contracting with licensed contraction;to
consumer de pmjcci(sac.7044,Business and Professions Cade:)The Coriander's Li-
cerise Law does not apply in an ownwr of property who builds or improvest lherton.and,
who contracts for such projects with a contrecloKs)licensed pursuant to the Contractor's .
License law.
❑I am eaempt under Sm .B A P C for Nis reason '
F, Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under pmulty of pedury one of the following declarations:
❑Thaw:and will maintain A CertlOate of Consent to self-insum for WorluYS Compcm
action,As provided for by Section 3]08 of Ne labor Code,for dm pedommnce of Ne
wank for which this .if is issued.
1 have and will maintain Woftes Compemallon Insurance,As required by Section
37W or de Inbar Cade.for the pedmmanee of Ne work for which this permit is issued.
My WarkAeA Crmpenxatim Insom "ce cartim and Policy number art:
artier: /sem Iicy No.:_W'3 OGO '7 G �a(/7
CERTIFICATE OF EK ONFROMWORKERS' O1.7`•�
COMPENSA ON INSURANCE I
(This section need not he completed ifihe Permit Is fmonehundred dollars(SIM)
of lesa) "
1 Moify that in the performance of the work for which Nix Permit is issued,1 shall not
employ any person in any manner an as so become subject o 1M WodmrS Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this CCNfieale of EaemPtion,you should
become subject to Ne Worker's Compvmatinn provisions of the IaMr Codc,you muss
,Z forthwith comply with such provisions or this Permit shall be doomed rooked.
'ZO CONSTRUCTION LENDING AGENCY
[-+► l hereby vMrm that there is A muwminn lendingagcndy forth.performance of
�i 'the work for which Nu pefmit is issued(See.3097,Civ.C.)
W A Lender's Name
a z Lende's Address
/\
U P 1 certify that 1 have read this city
and court and mm Net And
above ws mmtiun is
0 coned I agfoe a comply with all city and countyntati v s or and sum laws r up ing a
O V .1howngcoioncil ion,and for impaction
auNonertomsenuriv.of this city mcnmr upon Nc
C[7 ahovc-es,judgmnroPcityst for ex,i nwhich may
(-'C (We)agree to sate,indemnify and trap lurmleas the City of Cupertino agaimtHabi
Z inconcecue mofth,Stan and of this.awbich may in any way scenic against said City
V Z A APPLICANT
of UNDERSTANDS
of this Permit
^t APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE.REGGUL'ATIONS. /
—f_2'6_09 Re-roofs
Si of ApplicsnVConuatiew Data
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will the applicant or future building Occupant store or handle hsmrdous material
u defined by that Cupenino Municipal Code.Chapter 9.12.and Ne Health and Safety
COJc,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Y.411 gAo
Will Nc a Iicant or future Wilding occupant use equipment If a roof is installed without first obtaining an inspection,I agree to remove
pp g ec v w pment m dwices womb g P g
cmiL ha,,ardnue air c"maminanu As defined by the Bay Area Air Qualdy Management all new materials for inspection.
District?
❑Yes IPJNu
1 have eaJ Ne Imaatdtms mamrialsrtyuirtments unJer ChaPmr 6.95 of Ne Califor-
niaHaalN&Safety Code,Scedom 25505.25533 and 25534.1 undersmnd Nat if Nc building _
does not currently how• A.A.trnthat its my r.posuibility,to n"dfy the nm,.,of Air
myuimmcnuwhich must �iics.andc ,Signature of Applicant Date
Owner mtefthori,cd agent f- Data All roof coverings to be Class "B"or better
jat2.-13r
- G Pref
_ �.�l�-fid_.-• _.
-717
- - -
ell
rs6
_- IN ACCORD CE WITOH THE4ITY 0
CUP N E RD A --- - - OF
--
DATE-
SIGNEU.-.._ . --- - - - -- = - - --
This set of pian a lspe ications M
oe kept on the- etalLtimes and it i un �+ !
lawful to make any changes or alterat V3
on same-.without wtitEsn--permdssion f on - - - -- _ - - - _-_-----
the building Dept., Ci' ofCupvting;
NOT be h _and s cii, tins
-Th tamping of thhisug
, lanto permit to� ac
•p of of the_violation of an P "` E--CDPY
• .nu Gity O:dinanre or State Law.
-- - --- ---—1_ . -Guru%_co7=_�!5 _�=►L.�_•
,
*31
- , -- -- =-=-- —aGw,•P-rc- ----��'-�lL�.!'�'lG�c.l�.. _ �9G -�3L 6 !�1
IL
OF CITY OF CUPERTIN(O U 3�
COPCITY E TING PERMIT APPLICATION FORM o 3
APN# Date:
� � 3 - z 6 - 0'&f
Building Address: Mailing Address (if different from building address):
f 9v d ba-z, ' c
Owner's Name: Phone#:
/n**X-14 -S
Contractor: License #:
6t. :yo Lu.n 62 �/ 9oS
Contact: Phone: Cupertino Business License#:
.'clgG2/ Fax: 309-3428
Building Permit Info:
Bld 'OC Elect Plumb Mech
Job Description:
Residential ® Commercial ❑
Sq.Ft. Floor Area: q.Ft.:
Cost of Project: Occupancy onGroup:
'�
Type of Cstruction/ Please check this oject is Ea
o
second-story addition: ❑
Quanti Fee ID Fee Description 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
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 > 1 OOOA ELECTRICAL
BELEC200 Elec Svcs 600V<=200A ELECTRICAL
BENERGY Ener BUILDING
BENERGYADD Ener Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
BMITIGATC Comm. Housing Mit. FeeBUILDING
Iof3 �/� 32
OCITY OF CUPERTINO*
CITY°F PERMIT APPLICATION FORM
CUPERTINO
Quantity Fee ID Fee Description Fee Group
BNUCOMME New Comm Electric ELECTRICAL
BNUCONU M 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 cfm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Fumace MECHANICAL
BREMFURNOV Relo Furnace> I 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 Heatin MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, Marquee ELECTRICAL
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al
ITY OF CUPERTINO+
CITY OF PERMIT APPLICATION FORM -
CUPERTINO
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
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL Special Inspection BUILDING
BSWIM Swinuning 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
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