04030016 CITY OF CUPERTINO
BUILDING DIVISION PERMIT �`CONTRACTQRINFORMATION .
'BU0AR7G ADDRESS' POWERLITE ELECTRIC PERMRNO04030016
OWNER'S NAME: PERMIT ISSUE DATE
D' LEA LAYMAN 1661 SAmpnRA RT
ONE: SANITARY NO. CONTROL NO.
408 732-8651
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
s�0o LICENSED CONTRACTOR'S DECLARATION Job Description
I Wrathy affirm that I am Ikencd under previsions or Chapter 9(commencing P
Z with Sadon 7").f Divides 3 of dan Business and Prefessium Code.and my license is
�i ""<<�Imc el
Lk
o �(e3 �{I�r ADD BRANCH CIRCUITS/LIGHT FIXTURES
.
D Die• Conran' m r
Ut " ARCHDELTS DEC 10
1 um mnater d my plana.lull Te used s pffiIic records
;a� Luxused Pnttessional
OWNER-BUILDER DECLARATION
ii @ I hereby affirm that I em exempt from the Conlrumrs License Law for the
n o following much.(Section 70315,Business and Professions Cale:Any city or county
$ff which requires a permit to consmaci,Rlmr,improve,demolish,or rtpair any structure
FZsn prior to its issuance.alto requires the applicant for such permit to file a signed comment
8 that heisllcensodpursuant tothe provisions ofthe Contractor'lxxnseLaw(Chapter 9 Sq. Ft. Floor Area Valuation
(commencing with Section 7")of Division 3 of the Business and Profession Code)or
that M is exempt Nemftem and the basis fur the allegnd exemption.My violation of
Station 7031.5 by any applicant for a permit rvbken,the applicant to a civil penalty of Ell WT5eer0 0 Occupancy Type
not mart than End hundred dollars($500).
❑Lo th..rk...d pestmac or miminee sea wlNwegesotiahhak compew0'n,
will do thewoh,and th71he Cor is wee Lnded oro@rtt fs not appl(Secy
7014,B neer ss
of
and Prefexdons ldsor Tele vas un con,License law does not apply lf an owner is Required Inspections
own cro wit'bulldsoded that
sch improvements;
daewchwork h(mselredW'ugh his
own employees,provided Nal such imprewmmu art nollnnmded oronertd for sale.If,
however.Nebuilding or Improvementishaltwithinoro Wild
or improve
Ne owe of
builder will have the burden of proving Net he did not hulld or improve far purpose of
Able.).
❑I.as owrear of the property,am exclusively contacting with Ilex coed mnuumn to
construct the Project(Sec.7044.Buturcus and Profusion Cham:)The Consacmra U. E
RED,
cense law does nn apply m an owner of property who builds or(mprows tienan,andrwho contnesfor such proJeN with a conombar(s)Rumored pursuant a the Consume' kmm Law.Iam e.empl under Sec. .BkPCforthisressonOwner Dam
WORKERS COMPENSATION DECLARATION
1 herby afllrm under penalty of perjuryone of me following da tunions:.,
1 hate and will malnuin s CWEma ofConsenl m reit-kwm far WmkehCampcn-
mum,u provided for by Section 37M of me labor Cade,for the Performance of the
work for which this permit Is Issued.
❑1 have and will maintain WorkeYs Compensation Insutarla,As required by Schon
37M of the labor Code.for the peefroman<e of the work for which mu permit is Wood,
My Workers Compensation Insurance cannot and Policy number art:
Cartier. Policy No.:
CERTIFICATE OF EXEM Pnj&POMWORKERS
COMPENSATI I R,NCE
(This seed.meed hot W completed if the,permit is fm'ne hundred dollars(SIM)
or lea) .
1 certify me n me rformanee or me work fn which ria barrel,is issued.l shall not
crept a any man pran ol'become subject m de Wortrrsns
'Compeation
A,Pl1
NOT( E APPLICANT:Ir,after making this Certificate of Exemption,you Mot.5
becom enc to the Worker's Compensation previsions Of the Lahr Code,you mut
0 0 foMwi nobly with each provisions or this permit shall be domed croaked.
'Z y CONSTRUCTION LENDING AGENCY
j., (hereby ME.that mert is a obstruction lending agency for the perfurreance of
Ni r7 the work for which this permit is island(Sec.3097,Civ.C.)
aQ Lenders Name
z Lender's Address
U0 I certify mal I Ian read this application and state that me above information k
{s. correct.I agree to comply with all city and county ordinanar and state laws relating m
0 building construction,and hereby amboria mprewnutives Ofthiseity to cnar upon the
4i1 .hove-mmndoned Property for(npecdon purposes
py (We)agree m aha.indemnify and keep Tameless the City Of Cupertio against
y IiabilhcasYdlemnes,costa and expense which may in any wry see=against said City
U 7 in consequence of the Sharing o(thu Permit.
G
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dat
e
SOURCE REE2GUULAATT•IIONSSA/� ../`m�-yn4;
gnuurt OfA �i C"nuacmr� —1—� m Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will ma applicam or future building ucupant nom or handle hoartaw material
sa 111Xdr by time Cupertino Municipal Code.Chapter 9.17.and the Health and Safety
oris. 25532(a)?
01. a All roofs shall be inspected prior to any roofing material being Installed.
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
It hoaamoua air contaminams At,defined by the Bay Area Air Quality Management all new materials for inspection.
Diurlcd
❑Yns .0ltlo—
I have read the he ardousmauriahmyuimmwnu under Cha nmr6.95 o(the Califor-
niaHulthBSarnyca4,Seniau25505,25533 and 25534.1 understand mu if the building
does noi�t cu3rrs�gen�tlyc haw a tcmn4 drat it u my responsibility m notify. occupant or dm
r reOG °n be melpdartuiaRan=e'ncen(n'aa'r =y. Signature of Applicant Date
b� L DOte All roof coverings to be Class "B" or better
t J ncr or authoriz d agcm
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
aClOF Fax(408)777-3333
�UPEf�TINO
Building Department
JOB ADDRES PERMIT # p2, 8 9
/07R/ .13�rcfitifrGG b2 7
OWNER'S NAME: V LcA l,A kISN PHONE •pq 13 Z:9425-1
GENERAL CONTRACTOR: FAX #
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
a/ Electrical I'a0mum Pzctvc. 638+1
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
CITY OF CUPERTINO
CUPEI�r PERMIT APPLICATION FORM
N# / Date: .?—
Building
Building A dress: Mailing Address 6f diff ent fr building address):
Owner's Name: Phone#:
MEN LAINA /V
Contractor: License #:
*Fowcvllle -Ele.(Apac �38�1
Contact: Phone: Cupertino Business License#:
NAS Fax: 4W -1318 4x 1
ildin rmit Info:
Id Ele t Plumb ❑ Mech El
Jo De �y) L i
Residen is 9`—�"" d4m3ner i /
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: Occupancy Group:
Type of Construction: Please check this box if the project is a
secon- -story addition: ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILER1 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 <= 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
BMITIGATC Comm. Housing Mit. Fee BUILDING
#- 2 O(F�3 (y
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( � CITY OF CUPERTINO
CI7YOF PERMIT APPLICATION FORM
Ask CUPERTINO
Quantity Fee ID Fee Description Fee Group
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BOVERTWE Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
MIXTURE PbIg 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 Stonn/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 cfrn MECHANICAL
BREMAIRHAN A/C Units<= 10,000 cfm. MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation ofFumace 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
BREMSIGNAD Rmdl Sips Add Branch ELECTRICAL
BREMSIGNS Remodel Sips, Marquee ELECTRICAL
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CITY OF CUPERTINO
CITY of PERMIT APPLICATION FORM
CUPEkTINO •
Ouantity Fee ID Fee Descri tion Fee Group
BREMTHEATR Theatrical Lightinp Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct MECHANICAL
BREMVENSYS Ventilation S stems MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL Special Insection BUILDING
BSWIM Swimmin 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 MECHAI`T
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plu ing Permit Issue PLUMBING
PPLBG Plumbing Fee so foot PLUMBING
ZADDCHG Address Chane BUILDING
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