05050143 CITY OF CUPERTINO " •-
BUILDING DIVISION PERMIT CONTRACTORINFORMATION,
3Y!;re
BUILDING ADDRESS: PERMIT NO.
NOBLE CONST 05050143
W NER'S NAME: PERM.ISSUEDAM
ONE:
SANITARY OL NO.
ARCHITECTZNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
t� 0
u00 LICENSED CONTRACTOR'S DECLARATION
d C h SI leeby affirm Net I am licensed under previsions of Chapmr 9(commencing Job Description
U wismdun7000)of Division 3 of Ne Business and Professions Coca.and my license is
in full forte and effeet. 9NJ
yOi assns Cless Lic.N CHIMNEY REPAIR
11-0 Dam Contractor
ARCHITECTS DECLARATION
e, 1 undersand my Plans shall W upasew
sed as public rdt
Do<
U Ll.l
3 o G LiccrtuJ Pmfcssionel
S OWNER-BUILDER DECLARATION
Q0 1 hereby.. affirm on I em exempt from Nc Cantrdes Ce License Lew for N, LVCp ✓
oO followingteres Permit
]onstr Businessandmpr Re derau Celt:Any city os county
K$ which requires a permit or construct,alter,improve,demolish, file
repair any structure
'I—r^
Met
prithe incensed ourstartto Me the
ovisio so for such Courarmiuuccnm Law(Chapter
VaTuVG
n, (commisliwnudPursuantmNCPrevisionsofof Comraner'sLiccnuLaw(Chapscr9 Sq.Fl. Floor Area
w~$ (commencing with Section 7000)of Division Sof NC Business and Profossiom Codc)m
Nes he is exempt Nenefrom and the basis for the alleged eaempuon.Any violation of
Section 7031.5 by any applicant for a permit subjeca the applicant o a civil Penalty of 3 -,�er00 Occupancy Type
not more Nan Ove hundred dollar
0 1,u owner of the prefatory,or my employees with wages so their mle compensation,
will do Ne work,and the atructue is not intended or offered hotel.(Sw.7W4,Business
and Professions Code:The Convectors License Law dors not apply he an owner of Required Inspections
property who builds or improves;thereon,and who does such wort himself or through his
own employers,provided that such improvemena are not mended or offered formic.If.
however.the building or improvement is sold within one year of completion.Ne owner
builder will have she burden of preving Nat he did net build or improve for purpose of
sets.).
1,as owner of Ne property,am exclusively contracting with licensed contractors to
construct the project(Sec.]Bbd.Business and Profession Cade:)The Contractors Li.
cane Law deet no ply m ae owner of propeny who Wilds or improves demon,and
who conuacaf sac prole, withacontnnor(s)licensed pursuant to the Contractor's
License Law.
❑1 Nis mas
Ds
O N'DECGRATI
I hertby a,r onderpen yo peri w of de,following declani no:
I Ave and will aimaina Ngcm of Conunuo ul6insure Tor Worker'aCompcn-
sasioa as provid for by Sec an 37 of Ne Labor Code.for Ne performance of the
work farwNor is,sonit isi ocd.
❑1 have and will maintain Worker's Compensation Insurance,as reyumed by Section
37M of Me Labor Code,for the perfermance of On work for which this permit is issued.
My Workers Compensation Inntrom carrier and Policy number are;
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Cros section wed not W cempletc0 ifsne permit is forone hundred dollars(SIM)
,or IcssJ n
L cadfy Nat in Ne pvfmnxnce of Ne work for which this Permit is issed,I Or f,no,
cmployany personinany,manncrso mc come subject os Yed' s
Laws of .1; ;Z Dem
Applied., 02f x
NOTICE TO AP : ,af ng TL's m tion. ou sM1oulJ
Mcome suhjat to the Woh 'sl�omp.nsarum previsions f N.Isbnr Chdc,you mus
.JO rarthwitn comply with me provisions or this per 'unell deemed revoked. ..
Z CONSTRUCTION LENDI GENCY
p. I hereby affirm Nat there is construction lending agency for Me Performance of
a Ne work for which Nis permit is issued(Sec.3097,Civ.C.)
{L) 0Lenders Name
LY Lender.Addhom
�z
U C I certify Nat 1 hoot read this application and sum that the above information is
U, P eorect-I agree N comply with all city and county ordinances and save laws elating to
0U Wilding convection.and hereby auhome mPresemutives of Nis city N ever upon the
W aWn mentioned property for inspection purposes.
f~y (We)agree .indemnify and keep harmless the City of Cupertino against
Tn htfloiitiu,ludg=to of na,c nand oven which may in any way accrue against said City
U? APPLr CA UNDERSTnn DSSAND WILL COMPLY WITH ALL N.POINT Issued by: Date
SOO ULATIO . _
Z a9 SRe-roofs
sere of Apph V clot � De
AZARDOUS A IALS DISCLO URE Type of Roof
Wilith. plicantarfumre it gwcupanumemM1andlchaortodi mawrial
u dchwd by a Cupertino Muni C .Chapter 9.11,and Ne Health and Safety
out.Section 3532(a)?
p yes All roofs shall be inspected prior to any roofing material being installed.
o
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hazardous air contaminanuas�y the Bay Arca Air Quality Management all new materials for inspection.
istrict?
❑Ycs
Lha mad ehn nusmamriod.reMorememosundc,Chapmr6.95oftheCalifor-
Idoes
aHeadt Safety(: .Sc 'oas255(15.15533vu12553d.lundersand NatifN Wilding
no rarely hmc ant cook u my rnponipility N nntily time a uPant of de
qui awhich nmclprio luissusume.rsccNBtrum f ancy. • Signature of Applicant Date
amt M onle, e nt D All roof coverings to be Class "B"or better
Community Development
10300 Torre Avenue
f Cupertino CA 95014
Telephone(408)777-3228
� CITY OF Fax(408)777-3333
UPEkTINO
Building Department
JOB ADDRESS: PER119dTb
I S err
O R'S N PHONE #
@#NEP.-kt CONTRACTOR: ® FAX#
I am not using any subcontractors..,— -4", i L i a r
Sidnature Date
Please check applicable subcontractors an/complete the tollowing 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
She Rock
ile
942
2S
ler/Contr r Sign Dat
!1 CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPERTINO
APN # 0 ,2,— Date:
Buildin A dress M 'ng Address if efferent om building address):
Owne'r's Nam; �1 r �� Phone#: �
Contractor:„ / / � ff� License#:
Contact Phone: upertino Business License#:
e Fax:
Building Perm/it In
Bldg Elect ❑ Plumb ❑ Mech ❑
Job Description:
Residential ❑ L Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
rp
Cost of Project• �Q J Occupancy Group:
Type of Construction:) Please check this box if the project is a
AOL second-story addition: ❑
Pro ect Size: Standazd ❑ Laze Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> l OOK to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1 M to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/OfFComm/ nasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax—Resi/Mobile BUILDING
BELEC1000 Elec 600V <= IOOOA ELECTRICAL
BELEC1001 Elec 600V> IOOOA ELECTRICAL
BELEC200 Elec Svcs 600V <=200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
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CITY OF CUPERTINO
CITY OF 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
AL 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> IOK 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
BREM ESAPP Remodel Res Appliance ELECTRICAL
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e- CITY OF CUPERTINO
CITY PERMIT APPLICATION FORM
CUPEkTINO
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 Change I BUILDING
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