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04040080 CITY OE CUPERTINO BUILDING DIVISION PERMIT CONTRAC�?ORINrORMA'CIQN -* • BUILDINGADDRESS' PE ""'04040080 OWNER'S NAME: PERMIT ISSUE DATE CRIS JERBIC 04 /14 /2004 ONE: SANITARY NO. CONTROL NO. ARCHITECDENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH I= [� _op LICENSED CONTRACTOR'S DECLARATION Job Description e F I hereby affirm that I am licensed under provisions Of Chapter 9 Burnmencing p Sow withScctiunRM%1)OfDivixion3ofthcBusinessandPrufcssiansCnde,aadmyliccnscix ttI��In� ^ Z m mu maL�tl6e«e _/ - Lan •x�� 125 ELECT SERVICE �Uu�A�.E® Liccnsc Cl'ss ;roe Date — cmummioLLrAARRppj� z CONTRACTOR: TAP ELECT L �j�dcrsunJ my planeshal bcJDs puhll��cmJ MAY 1P 2004 JU toy Licensed Pmrcesional OWNER-BUILDER DECLARATION BUILDING 1 hereby affirm Thal 1 am exempt fru.the ComracwBUr's License Law for the p O following mason.(Section 7031.5,Business and Professions Cmbc:Any city or county K m which requires a permit Le construct,aper,improve,demolish,m repair any structure °iy prions itsissuance.also requires the applicant for such permiltufil... nedabremrd < = that he is licensed pursuant so the provisions oftheContractorsLicense Law(Chapter 9 Sq. Fl. Floor Area _ ValualV2050 ye-p broth mencing with Section 2000)nl Division 3 of the B usinces and Professions Code)Or i that he is acmpt therefrom and the basis for the alleged exemption.Any violation of Section 9031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type not more Nan five hundred dollars($500). C-]1,as owner of the pmi or my employees with wages s s their olc compensation. 35618059 . 00 will do the work.and the structure is not intended or offered for sae(Sec.7044.Business and Professions Code:The Commemrs Liecns,Law docs not apply to an Owner or Required Inspections property who builds or improves thereon,and who does such work himself Or through his own employ=,provided that such impronmcne are not intended Or offered for sale.If. however•the building or improvement is sold within one year of completion,me owner- builder will have the burden of proving mal he did not build or improve for purpose of sale.). 0 1.as owner of the property.am exclusively contracting with licensed contractors to eooswct the project(Sec.7Of4,Business and Professions Code:)The Contractor's Li. . Law docs not apply to an owner of property who Wilds or improves thereon,and, who o contracts for such prnje mwith a cnntractm(s)l icensed pursuant to the Contractor's Lice a.Law. ❑1 am exempt under See. B&P C for this reason Owner Data WORKER'S COMPENSATION DECLARATION ( 1 hereby off tm under,penahy of pc jury ow Or the following drelaratinns: Cu I hazeand will maintain aCenifieamof Conscramself-insum for Workcis Corton cation,as provided for by Section 3700 of Ne tabor Code,for the performance of the work I.,which this Permit is issued. I have and will maintain Worker's Compensation Insurance,is miquired by Section 3 Wof me labor Code,for the performance of the work for which this permit is issued. My Workers Compensation Insurance carie,tad Policy number r Per 1 Pal < CL' rf� El'r10N FROM WORKERS COMPENSATION INSURANCE Indiscretion need not W c.mplced irmc permit is for one hundred dollars(SBg) m lass) I sen ry that In the perfomlanee of the work for which this Permit Is issued.I shall not employ any person in any manner so as m Wcu nd subject to the WOskers'Compensation Laws of California.Date Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Worker's COmpcnsation provisions Of the labor Cole.YOU mato .J Z forthwith comply with such provisions or this Permit hall W deemed evoked. Z0 CONSTRUCTION LENDING AGENCY 'r+ I hereby a0itm that there is construction lending agency Or the performance nr Cli the work for which this permit is issued(Sec.30971 Civ,C.) Il.1 Q Under'e Name p• Lender's Address D Z. V 0 1 certify mu 1 ban read this application and sure,that me above information is DL F^ colica 1 agree to comply with all city and county ordinances and stole laws relating to 0O building eonswction rescmativcs of miscily to enter upon the shove-men' ropcny fur on polio. CL c)agree to save no y and keep I e -Y. Capacitor.against a ilams,judgmenw, d bellies which ny ardor.amslsaid City in consequence Lir lUf chis permit, ^' APPLICANT 'ANDS AND W O -WI L NON-POINT Issued by: Date SOURCE G NS es"i ` Re-roofs S' is of ltlicanV .nl r Date 115teRODOUS MATERIALS DISCL Type of Roof Will me applicant Lir future building Occupant store or handle hazardous material m defined by the Cupertino Municipal C e.Chapter 9.13,and lW Heabla and Sorely Code.Section 25532(¢)? ❑Yea All roofs shall be inspected prior to any roofing material being installed. Will the applicant or future building uccup. se equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove ,It horandous air sm umi as dew c B' At aAir Quality Management all new materials for inspection. laden ❑Ye 11 I timer char dues aterials vim under Chapter R 95.r the editor Na Hcalm yC .Seed 25N . 533 5534.1 undcrsendtherifthe Wilding drcs no allyl ae m. i my tomboy i ly[tic nxc of the r e ane' Signature of Applicant Date .act. t age Date All roof coverings to be Class "B" or better Community Development r ✓ 10300 Torre Avenue Cupertino CA 95014 Telephone(408) 777-3228 CITY OF Fax(408)777-3333 �UPEI�TINO Building Department JOBADDR PERMIT # 6�/�y OU�� /5-}'3 Sru,--rV J u v er7�v -O/ OWNER'S N L� C. PHQPJE #4 - 57O-,299/k, 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 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 i Tile /Contractor Signature Date 04/07/04 09:44 04087773833 CITY CUPERTINO 1002/004 ` CITY OF CUPERTINO CUPERTINO PERMIT APPLICATION FORM APN#3S_/ Date: G b l? a Building Address: Mailing Address(if different from building address): 15�3 Owner's Name: Ph a#: - f Contractor: License#. Contact: _,g4_gS97 Phone: S t/�/ ertino Business License#: - L 1 Fax: y ?5 ' /19- Building Permit Info: B1 ❑ Elect ® Plumb ❑ Mech ❑ Job Description: ` Q Residential - ,� E G iC P' J C�L��Commofci45 ❑ J glyl Sq.Ft. Floor Area: S/Sq,F,: Cost of Project: Q Cy7 e o Occupancy Group: Type of Construction: Please cbeek this box if the project is a second-story addition: ❑ ant' Fee ID I Fee Description I Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE ' Bldg Permits . foot BUMDING BBOILERI Boiler<-- 100,000 Blu MECHANICAL BBOII.ER2 Boiler> 100K to 500K Btu MECHANICAL BBOlI.ER3 Boiler>500K to IM Btu MECHANICAL BBOR"4 Boiler> IM to 1.75 M Btu hEAMANICAL BBOMERS Boiler> 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX bud/Off/Comm/ BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax-Resi/Mobile Bun DING BELEC1000 Elec 600V<== 1000A ELECTRICAL BELEC1001 Elec 600V> IOOOA ELECTRICAL BELEC200 Elec Svcs 600V r-200A ELECTRICAL BENERGY '. Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA - Investigation fee BUII.DING BMITIGATC Comm Housing Mit Fee BUILDING 57 I ora M E S S AG E C ON F = RMA T= ON DATE : APR-7-2004 WED 10:18 AM NAME : TAP ELECTRIC LVMR OFFICE TEL. : 19254499589 PHONE 14087773333 PAG& 1/1 STA TIME 04-07 10:16AM ELAPSED TIME 01' 16" MODE ECM BLACK RESULTS OK • --gut, CITY OF CUPERTINO CUPEI�TINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BOVERTIME Inspection Overtime BUILDING Fe ACKFLOW Atmospheric Vacuum PLUMBING VZ BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pblg Fixture PLUMBING L MBING 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 cfrn 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 > I OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non-Res Appliance ELECTRICAL BRE OLE 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 Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL 2of3 CZAR- CITY OF CUPERTINO CUP TYOF O PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Grou 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 Swininaing 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 3 of 3