05040121 C;1-NER'S
TY OF CUPERTINO
BUHANG DlvlsiON PERMIT �CON�TRACTOR�INFORMATION
DING ADDRESS: PERMIT NO.
JOHNSTON ELECTRICAL CONT CTOR 05040121
NAME: PERMITL UEDATE
E:
SANITARY 0 OL NO.
ARCHITECT/ENGINCER: BUILDING PERMIT INFO
BLDGELELT PLUMB MECH
o l� 0 0
ute00 LICENSED CONTRACTOR'S DECLARATION
I hemby affirm that 1 am licensed under provisions of Chapter 9(Commencing Job Description
wish Section 7MB of Division 3 m Ne Bmsiueas end Professions Cnde,end my liecns'
5 „ in murmur an erreqq �q ELECT. SERVICE UPGRADE
jgZ License Cl sygt ` lb Lic.p ` `�
¢F Date n'U l�ti Contractor l
QQ ARCHITECTS DECLARATION
1 understand my plans shall he used as public mentis Y�
a �y
30� Licensed Professional
OWNER-BUILDER DECLARATION
Y 1 hereby affirm Inez 1 am exempt GummInc Contractor's License Lew for the
M O following reason.(Secliun 7031.5,Business and Professions Code:Any city or county
$ which rore,a permit to ennsuucL alter,imprnvx,demolish,or repair any structure V�x
prior to its issuance,also"Gime the applicant for such permit to rile a signed su remcm
that he ishomsed pursuant to the provisions of NC Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuatio
(commencing with Section 7")of Division 3 of the Business and Professions Code)or
— Nal he is exempt therefrom and the bass for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a world subjcc.the applicant to a civil Penalty of
nor more man five handled dollars(5500). 3 ON A49T§cF 0 0 Occupancy Type
❑I,aowner of the properly,or my employes with wages utWir tole compcnsetnn,
willdo Be work,and me structure is not intended oroffered for sale(Sec.70/4,Business Required Inspections
and Pmfcsniona Code:The Conmaofs Lim.law does Out apply 1r.an ownere of q P
,,Open who builds or improves thereon,end who docs suchwork homelier through his
own employees,provided that such improvements we not intended proffer s!fertile.If.
however.me building or improvement is Gold within one year ofcompletion.the owner.
builder will have the burden of proving mat he did not Wild or improve for purpose of
sale.).
❑I,as be,of the"0'"y,am exclusively convecting with licensed contractors m
consumer the project(See 7044,Business and Pmfesrions Code:)The Contractor's Li.
cense law does not apply to an owner of property who Wilds or improves thereon,and
who contracts for such projects with a co minfor(s)licensed pursuant w to CnnlractOrl
Licence Law.
❑1 am exempt and,Sec. B&P C for his mann
Owner Dale
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of rW following dalunions:
have and will maintain aCeniOcne of Consent to self-insure for Wmise.Compere
1307M
n,a provided for by Section 3700 of the labor Code,for me Performance of the
for which this permit is issued.
have and will maintain Worker's Compensation Insurance,u required by Section
of the tabor Code,for the performance of me work for which this Nord,is issued.
Wor'�ke`(r'sCCompensation Insolence carrier and Policy number art:
eAll V��t fJi�cSs)[a±'[U Pol icy No.:Ore -LOO _ZLLJC
CERTIFICATE OF I,M ON FROM WORKERS'
COMPENSATION INSURANCE
(This seeuion need nol W completed Hthe Permit is for one hundred dollars(I10(B)
tar less.)
1 certify thin in the Performance of the work for which this Permit Is issued.1 shall not
employ anyperseen many mannerin is in Wcome subject tothe Workers Compensaton
Laws of California.Due
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compcutamn previsions of the"hot Code,you must
0 0 forthwith comply with such provisions or this Pemol shall W deemed revoked.
Zvy CONSTRUCTION LENDING AGENCY
PI hereby affirm that there is a construction lendingegency for the Performance of
Cd 7 tm work for which this Pemniu is issued(Ser.3(197,Civ.C.)
W Q lender's Name
z finder's Address
U O 1 certify ton I have mad this application and state that the above information is
Ik.F-h cmrcct.l some to comply with all city and county ordinances and rum lawsreslingm
OU building construction,and hereby toolimire representatives of this city to enter upon the
r W above-mentioned pmperty for inspection purposes.
(~ C (We)agree to save,indemnify and keep hsmlless IW City of Cupertino againsyt
TA liabllities,judmenc.,.,g .Col.aid eaaca which may in any way Carse agaimtaid Cit
U z APPL consequence
of the NDERranANDSthis
AND WLLL COMPLY WITH ALL oN. INT Issued by: Date
SOURCE RE L N
Z� Re-roofs
Sig na A plicaw cofactor I Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant tar future Wilding Occupant m handle havafdous material
a defined by IW Cupertino Municipal Code,Chapter 9.12,and IW Health a0 Safety
cmle,section 25532(.x! All roofs shall be inspected prior to any roofing material being installed.
C Vcs
Will the applicant of more Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hevafdous air Qtmamimmu,u defined by the Bay Alin Ail Quality Managcmcnt all new materials for inspection.
rill?
Yea
1 he.reW the toomfi nsombelf srequiremen.unikr Chapler695 of me Califon
hie Health&SafmySMe,Sections 25N15,255J7 aJ 25514.1 unJersuntl Nesifthe ilJing
does nor c ren yhove a Lenem,Net IL's my balsomiloy In w,flI I tof the
fcquimm aInch tart pri issuenceofaccnlficauof, /ru. Signature of Applicant Date
Owner or autbori cd agent Gate 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
WPEkTINO
Building De artment
JOB ADDRESS: PERMIT # J U 2-
4,20-37 Gt- sT CvIJ v l
OWNER'S NAME: L � PHONE S 4,-ZY(o Z
GENERAL CONTRACTOR: p o/�,�,J _FAX #
I am not using any subcontractors: 4A
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
Tile
Owner/Contractor Signature Date
amet
CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPEkTINO
APN # / D 7iZ_ Date: 2I —
Building Address: Mailing Address (if different from building address):
zc C(--
Owner's Name: Phone #
Contractor: License #:
39S�j(o �
Contact: Phone t1ur 24+6—P236 Cupertino Business icense#:
J' Fax: 234N
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech ❑
Job Descriptio Sim✓EC;✓
Residential 02C412Commercial ❑
Sq.Ft. Floof Area: $/Sq.Ft.:
Cost of Project: 4Qf, Occupancy Group:
Type of Construction: Please check this box if the project is a
second-story addition: ❑
Project Size: Standard Large ❑ Ma or ❑
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 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 Elee Svcs 600V <= 200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
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CITY OF CUPERTINO
CITY PERMIT APPLICATION FORM
CUPERTINO
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 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 > 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
M
BRERESAPP Remodel Res Appliance ELECTRICAL
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.. CITY OF CUPERTINO
cuPEr�TiNo PERMIT APPLICATION FORM
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 Ternp 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 Change BUILDING
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