05030126 CITY OF CUPERTINO
BUILDING DIVISION PERMIT .CONT.RA >TQR INFORMATIO.N• 7:
BUILDING ADDRESS: PERMIT N%5030126
OWNER'S NAME: PERMITMUEDATE
DAV
ONE: SANTIARY N0. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG EIPCT PLUMB MECH
0 0 0 0
upQ LICENSED CONTRACTOR'S DECLARATION
w❑ 1 hereby affirm Thal 1 am Richard under provisions of Chapter 9(commencing Job Description
zW with Section 7")ofDivision 3 of NC Rusinm and Prufcndions Cooke,and my license is
fdfall f.aeandeffect.
5 g z Lk.nu Class Lk.a TERMITE REPAIR/SEWER LINE/DRYWALL
_
Zz ,i, Dam Contraemr STUCCO OUTSIDE
2�2 ARCHITECTS DECLARATION
C I undersand my plans shall W used as public accords
Doti
e Licensed Professional
<I OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
HO O following mason.(Section 9001.5,Business and Professons Cade:Any city or county
m which mquires a permit to construct.alae improve,demolish,or repair any structure
prior us its issuance,also«quires tM applicant for such permit in file a signed suemmcnn
tR' that he is licensed pursuant mNeprovision¢ofthe Contractor's LicensLaw(Chapter 9 Sq. Ft. Floor Area Valu�t(n0O
,nti-a (commencing with Section 70M)of Division Sof the B usinns and Professions Code)or
y _
that he u exempt therefrom and Ne basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mom than love hundred d.11aa($500).
❑I,u..,of the property,m my cmployeu with wages u their I.compenu0an. 35714013 . 00
will do fie work,arta the swmum is not imm�&d arortemd f h ale(Sec.in im Business
and Professions code:The Contractor's ndwhis Law docs not apply lf an owner of Required Inspections
property who builds oded that such impr.andwho ams such work himalf m through His
ownemployxs,provided pr stenimprovementsarc not immndWordnmd for sax.If.
however,the building thor Improvement aid m within of year of mmtion for
the owner-- _
builder will have Nc Horden of proving that he did not Wild or improve far purpuu oP
sale). ED onstctneThCutedLcr.La tiroproject(Sec.n.. Business and.,whons C9ae:)The Consscomr'..lLd cove Liw dots not apply m an ower of propcny who Wilds or improves Nemon.lna.whocontranefor such projects with aeantactortUlimnadpursuannothe CrnuapM MLac
❑I exet under c. ,B&P C for Nis//j{,.c�tion �t '4t1Owe Dam IVS -
WO ER'S COMPENS7MON DECEACRATION -
1 hereby affirm under penalty of perjury one of the following declarations:
1 haw and will maintain a Ceniticam of consent to stir-insum for W.rkers Compcn-
sudon,u provided for by Section 3700 of the LiWr Code.for the performanm of the
W
for which this prom,is issued.
❑1 have and will maintain Workers Compensation Insurance,u required by Section
ITW of she Libor Code,for the performance of the work for which this permit is issued.
My Workers Compensation Irswnna artier and Policy number arc:
Cartier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu action need nolh.e9mplema train permit is for one hundred dollar(SIM)
or loss.)
I emifv that in Ne performance of the wok for which this permit is wood,I shall not
employ Uwsoanypersoninany man s Its yccomc subjttls9 NCNC Wori.iT��
Liwa of Cali rte oat
Applies t
NOTICE TO APPLICANT.the if.afar pens g Nm Certificate tri,Laborbo d you u must bmome subject y it Worh lure Compensation provisions of the rated Code,you must
.J O foMwith comply with such provisions or this permiuhall W deemed revokes.
Z " CONSTRUCTION LENDING AGENCY
[-�'A I hereby affirm that Vert is a construction lending agency for the performance of
C Nc work for which this permit is issued(Sec.309?,Ci,C.)
W0. A Lender's Name
Z Lenders Address
U Q I certify mat 1 have read this city
and county
and sus Net the s W el informniun u
0 fes' cora.t I agree to comply with all city and county oN ivOs of arta sum laws mining ue S
�C4 abildingconswdiogand hereby
mauthon purposes. lives of Nis city menmrupon N.
C. shout-(We) greeed to coy rademnify anliscip
H
C. (We)agree t^save,indemnify and kith harmless the y. of. gainsts id City
N l'abili' .juagm.nst,costs and expeu.s which may in any way acme agaiml said City \
C)z AHP LIC Mc of DERSTAN oS AND WILL COMPLY WITH ALL ON-POINT Issued by: Date ��
S RC R U S.
3 `Tor` Re-roofs
Signamrcof APPlica onractor r Daa
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant rr factum building meupam stem or handle hazardous material
cdefined by Oc Cupertino Municipal Codc.Chapter 9.11,and the Health and Safety
nde.s a 25532(a)? Q� All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding..part sea equipment Or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit ha'rardous air contaminants u dcfncd by the Bay Area Air Quality Management all new materials for inspection.
Dinrict?
❑Yes C➢
1 have mad he himand ms mammals requircmcnts under Chapter 6.95 of am Califor-
niaHco &Sorely Calc.Sceuou25505.25533and15534.lun&mwdNmifthc Wilding
does t t ¢nam.Nat'l w my rmsrwmi iy m notlly am oc opann of Nc
req mine Ow ch met potoI r aCe mam.fOccup rY. Signature of Applicant Date
Owner tar aulhomcd agent Me,3�4All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
It
ZIM,
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408) 777-3333
�UPERTINO
Building De artment
JOB ADDRESS: PERMIT #
Icy a r,,i- CA o
OWNER'S NAME:'Z>&, ,XQ'X.L Q 1--Er— PHONE # Y4? /
GENERAL CONTRACTOR: Caz % 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
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
' e
Owner/Contractor Signa a Date
IT
CITY OF CUPERTINO
CUCITY
TYOF O PERMIT APPLICATION FORM
0.56 3 0/ 67
APN # Date:
3�7 - ly - fll3 3I4/oi
Building Address: Mailing Address (if different from building address):
Wy8q 3 f-ve C4
Owner's Name: Phone #:
FS167
Contractor: License#:
Ga�Q `733e{q'?
Contact: Phone: 41-12-4114-o�zFr Cupertino Business License#:
(Jc6«I Fax: -lek-
Building Permit Info: I
Bld 'E Elect ❑ Plumb ISL Mech ❑
Job Description-
ResidentialLJ ��ce�[ Sacco aJ%,cL Commercial ❑
Sq.Ft. Floor Area:-lec rcVm4-, Se-. I,'- $/Sq.Ft.:
t?5 S 0
Cost of Project: Q 6�O Occupancy Group:
Type of Construction:` Please check this box if the project is a
second-story addition: ❑
Pro ect Size: Standard ❑ Lar, e ❑ Ma'or ❑
uantit 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> IM 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
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iQ.: CITY OF CUPERTINO
CITY 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 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 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 HeaterNent 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 Furnace MECHANICAL
BREMFURNOV Relo Furnace> IOK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Mise 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 A liance ELECTRICAL
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CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPERTINO
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 Inspection 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
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