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05090055 CITY OF CUPERTINO wX 'Ap PERMIT �kF,,ON�T�R�kC-T,,OR�4NEORMA-T�ION'-,,�tI BUILDING DIVISION ING A... 4 JOHNSTON ELECTRICAL CONTRACMWO05090055 Ro �e OWNERS NAME: PERNUT ISSUE DAM /,/,-Ze2 16V122,11W,6:— 1840 ALMADEN RD. #3 09/08/2005 NE: V SANITARY NO, CONTROL NO. (408) 266-0236 ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDGI MECH pn 1100 LICENSED CONTRACTOR'S DECLARATION tit I hereby affirsto that I am licensed under provisions or Chapter 9(commencing Job Description and Code. F% _Z. f * sC do midonylimostris GPO* EL (20 onfitillf.renturideffect. UPGRADE ELECT. PAN OAMP') ,nZ LimisexChus; _Lm. 4ALEU Zt , DanCumrecto — ARCHI O&..d in,plans shall W used as public manilm 0 2005 u.t; Licensed Prumigum"ll .n OWNER-BUILDER DECLARATION I hereby affirso As(I am exempt from the Contractors License Law for the O'a S: 0 following reason.(Section 7117 L5,Business and Prodicamons,Code:Any city or county I6�. which mmore,a Permit to construct.also,improve,demolish.or repair any shoehorns, INN r,0 0 ��O prior to its issuance,also requires the applicant for such Permit to rile a signed gaimeent that he is licensed pursuant in the provisions of the Contruclor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation 5�0 (commencing with Section 7")of Division 3 of the Business and Professions Code)or A.,be,4 exempt museftiond and the basis for Am alleged exemption.Any violation of Section 7031.5 by my applicant for A pari subjects me 11pplirand 10 2 Civil penalty Of APN Number Occupancy Type Out..thour Rw hundred dollars($50X0). 075 will des the work,end cammmume is not thoughled monitored intuit.Sm.7044.Busi. and Professions Cram:The Commaguou's Liccouss,Law does not apply to an Owner of Required Inspections pm,,rsy who buildsorimprodwas Agnsion,and who doessuch work thirroxformough his Own employees,provided Out such improvements art not intended at offered for We.If. however.me building or improvement is sold within one year of completion,the owner- builder will have As burden of proving As,he did not Wild or improve for purpose of .I.I C]1,as owner of the property,am exclusively contracting with lichroud contractors to construct ffic ussoct(Sec.7044,Basin.end Pos(tion..Codes)The Commerce,Li mium Law does not apply in in owner of property who Wilds or improves Armon,and who contracts,for such projects with a contiamer(s)licensed pursuant to me Conerserat's Licenam Law. 1 1 am exempt under See 8&P C for At$hations Owner Date— WORKER'S COMPENSATION_DECLARATION I hereby mE.mmm,penalty or poij.,ma,of the following dighmalimcs: I haw and will maintain a Ccodfimbc of Consent to silf-n for Woolum's Comper- .,for .provided for by Section 37M of the Labor Code,for the parfignorm.of A. work for which this Permit I.issued. 0 1 have and will maintain Worker's Componsications Insurance,as"Whed by Section 137W of Labor Code,for As jactformanes of weak for which this permit is issued. My Worker's Compensation lionsounce carrier and Policy C C. myW"'M�20'., anner:'tDSAJA Policy No CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not to completed ifflue Permit is forom hundred dollars(SIM) or less.) I mot Oat in the performance of Oc work for which diii Permit is issued,I shall nor employ any Nixon in any manna A as or become subject to the Workers'Compensation Lawa of California.Dam Applicant NOTICE TO APPLICANT:If.offer making this Cenificisto of Exemption,you Amid becons,subject to the Worker'a Com,scrunifirm provisions of dus Labor Core,you mug Z fichrimifth comply with such provisions or mia ,.I,All be deemed revoked. Z C E�; reCONSTRUCTION LENDING AGENCY I hereby arion that them is a commucLon[ending agency for the performance of Ne work for which this permit is issued(Sec.3097,Civ.C.) Laurie AZ L D z J 0 1 certify that I have head this application and state that Ac above information us correct.I agree to comply with all city and county ordinances and sure laws miming to building construction.and hereby amhorim mpreminsfiven Of this city do emer upon Au shove-mmunincil pax,exty for inspection purposmea. (Wo)agree to saw,indemnify and Imp harmless the City of Cupertino against liabilities,judgments.com,no sarcoma which may in any way imme against mid City J z . Of ranting of this permit. n ong u Of STAND ' 511 VN APCPIIC'A U D�ZP SA 04POINT Issued by: Date nNZILOMPLY WITH ALL SSUe U 0 Is jJKK 2? ��> Re-roofs Si azo uC or au HAZARDOUS MATERIALS DISCLOSURE type of Roof Will As applicant or ruttic Wilding Occupant mom or handic hazardous material u defined by thm Cupertino I Codr.Chapter 9.12.and Ne Health add Safety Code.see Yes 25532(a)7' V-7 All roofs shall be inspected prior to any roofing material being installed. Yes n Will the applicant-I or Irbuilding Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove w'Of to min it burandous air mulmnin v defined by the Bay Area Air Quality Management all new materials for inspection. District? s i"c" 0 Yea, have I how mid!the hoaselousmaterials mquircommis,underChapter6.95 of the Califico- 1 c As Health&saf,"C Smu 255�10 '25�iby umkrsuMdy,t)irilf ilums off tion does nos cunscoul h. n,1u it n'Wm me requirementsw c 7 c I Signature of Applicant Date gen All roof coverings to beClass "B"or better 0.ern in. c 4a9cipafe Community Development ' 10300 Torre Avenue �Lo' Cupertino CA 95014 Telephone(408)777-3228 CITY Of Fax(408)777-3333 UPERTINO Building De artment JOB ADDR3SS: �7� PERMIT # L1 'IE% L O OWNER'S NAME: L CA-A PHO o$ z4, GENERAL CONTRACTOR: tJ I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete 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 Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date Elm- CITY OF CUPERTINO CUCITY TYOF O PERMIT APPLICATION FORM 0-( N# 3 ( 63Date: Q �i Buildingess: Mailing Address if different from building address): D'1�-- � . nl(S ti Owner' Name: Phon • E c\'t, ( 4DqR4(, -4'76 Contractor: � License#: a Con r n Phone- --07.3` Cupertino Business License#: CdL Fax: -631Z3�1 Building Pe it Info: Bldg ❑ Elect Plumb ❑ Mech ❑ Job Descrip ion" Residential 1 N (J } Z rcommercial ❑ Sq.Ft. Floo Area: q.Ft.: Cost of Project: Occupancy Group: TypeEofonstruction: Please check this box if the project is a second-stor addition: ❑ro ize: Standard Large ❑ Ma'or ❑ 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 Boiler> 500K to 1M Btu MECHANICAL BBOILER4 Boiler> IM to 1.75 M Btu MECHANICAL BBOILER5 Boiler> 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX hid/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> IOOOA ELECTRICAL BELEC200 Elec Svcs 600V<= 200A ELECTRICAL / BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING 1 of f r alb CITY OF CUPERTINO °F PERMIT APPLICATION FORM CUPERTINO -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 BOVERTME Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum . PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pblg Fixture PLUMBING BPGAS Gas Pipinj 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 InstaWAlter Water Pie PLUMBING BPWHEATER Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit > 10,000 cfln MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfin MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT 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 Devi ce/App aratus ELECTRICAL BREMRECEPT Rcpt], Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL 2of3 agar"BitSip 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 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 MPERINUEE 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 3 of 3