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04030077 I' CITY OF CUPERTINO BUILDING DIVISION PERMIT I.GONTRACTOR INFORMATION BUI LDING ADDRESS: TOM ' S PLUMBING PERMITNo.04030077 1121 CHAnWICK 21 OW NER'S NAME: PERMIT LSSuE DATE JIM BR ONE: SANITARY NO. C04 NO. (408) 867-6010 ARCHITECTrENGINEER: BUILDING PERMIT INFO BLDG EIPCT PLUMB MECH 0 0 0 0 Lpp LICENSED CONTRACTOR'S DECLARATION JbDescri Description ZC 1 hereby erfirm Nat 1 am op licensed under provisions,of Chapter 9(commencing<U with Scction]gM))of Division3oflhe Business end Profcssioiu Code.and mylicenu is ^ Or In full force and eR`� I 5ya Lfanwclaa Lk.N L 1Ag GAS LINE �rn\ a:F DatesClass. Twp Cantncta lJ ARCHITECTS DEC ATIO f I undersand my Puns atoll be mud as pis lie RLOr1Is ,6U \� Licensed Pmressinml \ g OWNER-BUILDER DECLARATION 00 I bemby.Item on 1 1.3. exempt from The Contractor's License Law far Ibe o O which re reason.Section i 71D construct. Business and Ra.cssiuns Code:My city or county $� which rtyuims a pewit m conurucL alter,improve,demOlinh,or repair any sweturc Fibprior ha is,issuance.also mquircs the applicant for such Permit to file a signed statement that he is licensed pursuant no the previsions of the Connector's license Law(Chapter 9 Sq.Ft. Floor Area Valuation ¢�$ (commencing with Section 7000)of Division 3 of to Business and Pefcu mus Com)or — Nal he is exempt therefrom and the bass for the alleged eaem d on.Any violation of Simeon 7031.5 by any applicim fon permit subjects the applicanuo a civil penalty of 38�dI'IZD161'CIer00 Occupancy Type nut mom Nen Bs hundred dollars(5500). ❑Ido eworaf Ne propeny.on Isnot Warded m orreogeassNe'vule 10,W,Blsa0on, will do Ncwart ands: he Comunot intended Orawit for sok(Sec.W an ow.of ane PrtywhoW Calc:The Contracton,License law docs ton apply lf an owns, is Required Inspections Own property who Wilds improves;donator improvements on q and who me wok M1imuRml form at M1f. ownemployees.providedimprovement id within nen tendedmpledn.the own,.. Wilderhowever.the building or improvement is hatd within one year or completion.the owned Wilder will have the burden of proving that he did mut Wild or improve for puryo¢of sale.). ❑1,a mune,of the property,am esclusively contracting with licensed contracmrs to construct the project(Sec.70,1,4.Business and Professions Code:)Than Conuuor's Li. cense law does not apply to an owner of property who builds or improves thereon,and who conexcu for such projecta with a contractors)licensed pursuant to the Contnntoes Lkcmw law. ❑ I am exempwnde,Sec. ,B&P C for Nis reason Owner Date WORKERS COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury One of Ne following declarations: I have and will maintsin a Certificate of Consent to self-iosum for Worker's Condon. titian,u pmvidcd for by Section 3700 of tie labor Cade,for the perforrim.of the work for which this permit is issued. ❑1 have and will maintain Worker's Compensation Insurance,Is required by Section 3700 of the labor Code,for the perfmiumee of the..,it for which this Permit is issued. My Worker'rs��yC-�omm�pema�t�ion h�ummnce carrier and Policy number am: Cagier. a'aiT�s'k�a/�a�� Policy No.: �r1 IIVZ7y7 CERTIFICATE OF UEMPTION FROM WORKERS' COMPENSATION INSURANCE rrnu=rim need not uncompleted lithe Permit is foronc hundred dollars(SIM) or Pus.) 1 certify that in the pornmance of the work for which this Permit is issucd,I shall not employ any person in any manners,as to become subject o the Workers Compensation laws of California.Dau Applicant NOTICE TO APPLICANT:If.after making this Cenificam of Exemption,you should become subject to the Worker's Compensation previsions of she Lahr Code,you must .J Z forthwith comply with such provisions or this permit shall be deemed revoked. ?O CONSTRUCTION LENDING AGENCY 'ry Ihereby airier Nat Nert is a communion lending agency for the perfurmana or �ithe work for which this permit is issued(Sec.3017.Civ.C.) W� A Linder's Name 0 Z LCMer's Address U 0 I certify that I have read Nis agpliation and sou that the above ofmmauun u coned.1 agme to comply wish all city and county ordinances and tau laws mlating no 0 U building Consuction,and hereby amhOHM represcnatives of this city to enter upon the r 6 aWw-mentioned Property for inspection purposes. (We)agree in sats.indemnify and trop harmless the City ter CuPcnino against liabilities,judgments.costs and expenses which may in any way arcmc against said City U in consequence of the granting of this permit. ^' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINT Issued by: Date SOURCE REGULATIONS. Re-roofs sum&Applicmi,Cmuraetor Dae HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicam ser future building occupant sort or handle hav tudr material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety ,jIlWadc.Seeders zs5324)1 used to 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 emit havardour air oanamimnm ss acryea ray Ne Bay tea Aim Qualhy Manasemcm all new materials for inspection. District? / ❑Ycs OMr 1 hate read the Wrallous materials requirements under Chapm,6.95 of the Califor- ni.k.IN&Safety COdc,S.ti.25505.25533and2534.1undcrsund UotiftM Wilding deet not currently haw a tenant.that it is my mspermibinty b notify the Occupant of the requimments which mug be met toissuance Or accFam or Occupancy. Signature of Applicant Date Q net or uthoricaagent Dam I All roof coverings to be Class "B"or better ' Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 �UPERTINO Building Department JOB ADDRESS- C !/��JC,f ch. a1171p PERMIT/ / / 2- / O 36 X77 OWNER'S NAME: ;i kn PHONE # qG- Z 6G U GENERAL CONTRACTOR p #2 /S vM /N 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 V PlumbingI o m 1 S ��V 111,41 Roofing Septic Tank Sheet Metal Sheet Rock AN Tile Vl-1 Owner/Contractor Signature Date 1 �- CITY OF CUPERTINO cuP TYOF PERMIT APPLICATION FORM � � ' 3 J � 77 APN # Date: Building Address: "Mailing Address (if different from building address): II / ? I r h w;C4 loto � Owner's Name: /- Phone#: `l :Y1WC ✓S - ` q�(�d Z �o v Contractor: / License#: Contact: Phone: ` 7 F1 b Cupertino Business License#: �N Fax: Z Building Permit Info: Bldg ❑ Elect ❑ Plumb ® Mech ❑ Job Description: C1 S �N,6,r Residential / Commercial ❑ Sq.Ft.,Floor Area: $/Sq.Ft.: Cost ofProjeclk Occupancy Group: 704 Type of Construction: Please check this box if the project is a • second-story addition: ❑ Quanti Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILERI Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> 100K 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 <= 100oA 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 7� 1 of 3 � q/ . U� a-m CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPERTINO -Quantity Fee ID Fee Description Fee Group BNUCOMNM 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 I 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 rinklerBackflo 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 cfm MECHANICAL BREMAIltHAN A/C Units <= 10,000 cfrn MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BRENff URN 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 Device/Apparatus ELECTRICAL BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BRENfRELOCA 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 2 of 3 CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPEkTINO Quantity Fee ID Fee Description Fee Group 13REMTHEATR Theatrical Ligliting 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 BSWlm 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 ZADDCHG Address Chane BUILDING 3 of 3