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05040122 ;UI,1DINGADDRESS: Y'i7E CUPER'rINOuuu.mrvc lirvlsiory PT✓RMIT �;CONTRACTOR INFORMATION k PERMITNO. JOHNSTON ELECTRICAL CONT TOR 05040122 BRGGKWEEIL BR ' AM PERMITISUEDATE E: SANITARY /2 1OL NO. ARCHIIEC(ENGINEER: BUILDING PERMIT INFO BLDG ELECT' PLUMB MECII 0 0 0 0 +0, LICENSED CONTRACTOR'S DECLARATION Job Description p I hereby affirm that I am licensed under provisions of Chapter 9(commencing mm4K with Scmlon)(sM)of Division 3 of Nc Businessend Prufessinns Cnde,end my license is ^=e infullfm ad ct. ,qz cane s ie. 'I ELECT. SERVICE UPGRADE COntrseer N ARCNrtECTS DECLARATION Ky << I understand my plans,hall W used u public mentis OyU 3 Licensed Pmfcuicnal 0 +03 OWNER-BUILDER DECLARATION .�n q 1 masa affirm that 1 1. exempt s an the Cssions o License Law for the p O following arson.(Section?II3L5,Business and improve. dernns ts,or Any city or county $ which rots as a permit re cnnswct,plug improve,demolish,car mane any statement t-Za prior to issuanro,Alin requires the applicant forsuch Permit file e,igned statement that he is licensed pursuant the provisions of Ne Comr,wim's Liecnse law(Chap¢r9 Sq.Ft. Floor Area Valuatio y�0 (commencing with Section 700(pof Division 3 of HC Business and Professions Code)or y Nn he is exempt therefrom and Be basis for Ne alleged exemption.Any violation of Section?031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than fin hundred dollars(5500). 3l7'�d]7 IV PWR1 r00 Occupancy Type 1,u owner of rhe property,or my employes with wages u Amir sole compensetlon, will do the work.and the structure is not inundcd or offered forsale(Sec.7064.Business and Professions Cade:The COneracmh License law does not apply to an owner of Required Inspections property who builds or Improves Hereon,and who daeasuch work himself or through his n cmplo e Wilding ing or that such improvements are not intended orofiercd frossda. builder one bw i e b r impm arrem proving hat bee i in ott year of c prove nin.for pu ownen j builder will have the burden of proving Hu he did not Wild m improve for puryose Of salc.l. ❑1.as ownerof ct See 70y..Ballusively contracting wIHlicensed Contractors t. cense La Be project(Sec.?o CC,Business and property wh Som Code:)The vet thecton.Lid cense law contracts not apply a an owner of pmpeny who selids of improves thereon,and O who .Lw.for such projects with p cOnuacmr(p licensed pursuant to He Contractor's 0 1 am Law. ❑lam&,crops under Sec. ,B&PCfor this rcsson 1107.1 r Data WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of the following declarations: ave and will maintain a Certificate of Consent sel6lnsure for Worker's Compcn- ,as .filed for by Section 3]011 of He labor Code,for He'If....of the for which His permit is issued. ave and will maintain Workers Compensation lnsumt[c,u required by Section of He labor Code,for He pmformance of the work for which His Permit is issued. orkmes Compensation Insurance Cartier and Policy number art:: r. IC l l Policy No.:ay- nlo2z, CERTIFICATE OF EKON FROM WORK ERS' COMPENSAT NINSURANCE (This section need not the completed ifne permit Is for one hundred dollars(Slip) Or less.) I really thrr in the performance of the work for which this Permit Is issued,I shall nal employ any Perm any manner seta subject to become subjeco the Workers'Compensation Laws of Cdforn iia,Date Applicant NOTICE TO APPLICANT:IL after making His Cendicam of Exemption,you should become subject to the Worker's COMIPOMation pmvisiom of the Labor Code,you must .J O forthwith Comply with such provisions or this Permit&hall W deemed revoked. ZN CONSTRUCTION LENDING AGENCY [—e I hereby affirm that Here is a corm ando lending geruy for Performance of Be work for which this permit is issued(Sec.3097,Ci,C.) IT•t 0lender's Name D a. lender's Address U Q 1 cenify that 1 have read His application and sonic that the above information is W P correct l Bgrce to comply with all city and county odinincer and sure laws relating to O U building construction,and hereby authorire mprcsenutiscs Of Nis city to enter upon the W above-mentioned property for inspection purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino against eFi N Iiabilitiesjudgmcnu,costs and expenses which may in any way accrue against send City V Z to consequence of the granting of this Permit. APPLICANT UND RSTANDS AND WILL,COMPLY WITH ALL ON- DINT Issued by: Date SOURCEREGUL 10 _ Re-roofs ignamrc P 0 HAZARDOUS MATERIALS DISCLOSURE D u Type of Roof Will He applicant or future building Occupant tore or handle hamdous material as defined by the Cupertino Municipal Code.Chapter 9.12,antl be HcalH and Safety Code,Sec tion 25532(.)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes u 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 haradous air contaminants as defined by the Bay Arca Air Quality Management all new materials for Inspection. talcs? ❑Yes I have:read the no.ob rs m.urialsmquimrnents underchipur 6,95 ofthe Crido. iia Health h SafcryCMc,Sretions25505,25533 and 25534.lundcrstaud Har if Wilding dors not ctommly ha '.tenant Hat it is y responailZliry m nuuty r we pot of tic require nuwhi st met at suanccofeC 'ficKu,01 up y Sig nature of Applicant Date rm atrmnriued ag cat D� All roof coverings to be Class "Be'or better • x Community Development 10300 Torre Avenue i ! 1 Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 UPEkTINO Building Department JOB ADDRESS: PERMIT # d J DL-) 0 f 2-L OWNER'S NAME: v q� PHONE # L( ZSZ— GENERAL CONTRACTOR �l-5� FAX # I am not using any subcontractors: OJ Signature Date Please check applicable subcontractors and complete the followinginformation: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Excavation t cing ring: Carpeting oleum/ Wood s/ Glazing ting Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date ZINN CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPEkTINO APN # Z oO Date: `T l Building Address: Mailing Address (if different_from building address): WDL401 �F20DIL J(2te� C S �-4 Owner's Name: Phon #: �8)z5 - L/ Coptractor: /1 License#: ,D)Al oN _ 73R -!E�R(-,8 Contact: hone: `tris Zro�-oz3t- Cupertino Business License#: V)101 TD�k Fax: uy b33&' Building Permit Info: Bldg ❑ Elect Plumb ❑ Mech ❑ Job Descriptiop: Std✓>G� Residential G rZ A-06�'— Commercial ❑ Sq.Ft. Floor Area: S/Sq.Ft.: Cost ofProject:_I Occupancy Group: S5'60 Type of Construction: Please check this box if the project is a second-story addition: ❑ Project 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 Boiler> 500K to IM 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<= 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 I of3 ( 0 3. CITY OF CUPERTINO CITYOF 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 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 cfin MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace >1 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 Ap Hance I ELECTRICAL 2of3 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 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 3of3