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05030215 a CITY OF CUPERTINO ' = BUILDING DIVISION PERMIT CONTRACTOR INFORMATION �' BUILDING ADDRESS: PERMIT NO. 05030215 OWNER'S NAME: - PERMIT ISSUE DATE HENRY TING SANITARY OL NO. !�GNE: RCHITECf/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 lino LICENSED CONTRACTOR'SDECLARATION u+FC 1 bunch,affirm that I Am licensed ander proviumom u of Chapter 9(cmencing Job Description iW with Sauvm]000)of Division 3 of the Business aM Prefemiou Coils.and my license is ?iso infullforee and erten._ (� jgg ucenacelam e!ara aidd tie.» CHIMNEY REPAIR n ^q Date 3-9a_na Contractor CONTRACTOR: MR. CHIMNEY VMASON CONST. 7 ARCHI'IECI'S DECLARATION N a 1 mbenund my plans shall W used.public /U records 3 ,tat; Lccnud Professil ona 3 OWNER-BUILDER DECLARATION .�i P 1 hereby affirm that am exempt fromm Usee Contractor's License Law for the 20 following mason.(Section](131.5,Business and Professions Code:Any city m county m 6� which onquires a permit to consent.allu.Improve,demolim.Or repair MY structure n Ana / 7n rZi prior w its issuance.also requires lW applicant forsuch Permit to file a signed statement fY ss`o that he isliccvcdpursuant tothe provisions ofthe Contractors Liecn¢law(Chapter 9 Sq.Ft. Floor Area —kv//�� " M0VaIuarOT200 rot- (commencing with Section 7")of Division 3 of the Business and Professions Cmlo)of y $ that W in exempt bereft=and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit aubjecu the applicML10 a civil penalty of APN Number — Occupancy Type UU not mom Nan fins hundred dolt. 0 i,uowncrof Olepmpmy,mmyemployeeswinswagesu IMirolecomPemdon, 35618028 . 00 will do the work,and the secmrt is notimendcd afoffemd for ale(Sec.]061,Business and Professions Code:The Contractors License Law docs not apply m An owner of Required Inspections propeny who builds or improves Semon,and who does such work himself or Borough his own employees,provided that such impmwmeno are not intended or offered for sale.If, however.Ne building of improwmem is old within ane year of Completion.the owner- Wilder will have the burden of proving that Ins did not build or improve for purpose of ale.). 0 1.as owner of the property,am exclusively contracting with licensed contractors to construct the pmjcct(Sec.]Obs,Business and Professions Code:)The Contractor's Li- cense Law docs not apply to in owner of property who Wilds or improves Semon,Md. who contracts for such prejec s with acontraator(s)licensed pennant to the CmnlriLlmra License La- 0 I Am excmm under Sec. B&P C for this much Owner Data WORKER'S COMPENSATION DECLARATION 1 hereby affirm track,Nesity of perjury one of doe following declarations: I have and will maintain a Ctmficate of Contin w til(-hime(or WorkersComPm- section,As provided for by Section 3700 of the Labor Code.for the performance of the work for which this Permit is issued. I have and will maintain Weikcrs Compensation Insurance,u ee required by Suon l]00 of Nc L or Cods,for the performance 9f Ne work for which this pen it is issued. My Workers ComPeuation Insurance carrier and Policy number m: Carver. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' ' COMPENSATION INSURANCE (Thu rection need not hecompleted BIK Permit is form=hundred dollars($100) or loss) 1 certify that in the performance of the work for which this Permit is issued.I shall not employ any personinany mapperssj IyhemOaubject to the Workesi Compensation Laws of Calif Z -_. Applin est NOTICE TO APPLICANT:If.of 'along this Certificate of Exemption,you should become suhjwt w the Worker's Compensation previsions or do Labor Code,you mast .,O foMwith comply with such provisions or this permit shall W deemed revoked. - Z� CONSTRUCTION LENDING AGENCY (-+ I hereby Affirm that them is a construction lending agency l'onhc performance of C' > the work for which thin pernit is Acted(Sec.3097.Civ.C.) 1a Landers Name 0.z Lender's Address U 0 I sonify Net 1 have read this application and Auto that the above information is E' correct.I Mire to comply wish all city and county ordinances and stain laws relating to DU Wilding construction,and hereby authome mfresemoves of this city to enter upon Be r[21 move-nomioned property,for inspection purposes. (We)agree to sass,indemnify and keep harmless the City of Cupertino against wFi faA liabilities,judgments.costs no expenses which may in any way accrue against aid City of dre granting of U Z APPs Permit, CLICAcNTUNDERSTANDS AIND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE REGULATIONS. Re-roofs Signature or Appr MYConua r Dale HAZAgV0USMATERIALSDISCLOSURE Type of Roof Will the applicant Or future building Occupant atom or handle haeramous material As de0ncd by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety code.Semon 25532(.)' All roofs shall be inspected prior to any roofing material being installed. Yu V Will the applicant or future building occvpam tau cyuipmcnt or devices which If a roof is installed without first obtaining an inspection,I agree to remove it hazardous air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection. asst] 12/ ❑Yes gp Nu ' 1 have mad the hexamlws mauoals requiremcmu under CoMic,6.95 of the Califon .is Health&Safety Code.Seeuou 25505,25533 and 25536.1 undersand that if the Wilding does not Curcmly haw a mom.that it is my maponsibility to nouly the Occupant of the mgainements which muss be met poor wiaaance of a CcNficaic of Occupancy' Signature of Applicant Date tui �'�y All roof coverings to be Class"B"or better Owner or amhorized agent Dau Community Development 10300 Torte Avenue " Cupertino CA 95014 Telephone(408) 777-3228 CITY OF Fax(408)777-3333 �UPEkTINO Building Department JOB ADD0RE SS: PERMIT # psZ 3 ZlSJ OWNER'S NAME: PHONE # a e)a a GENERAL CONTRACTOR: FAX # I am not using any subcontractors: kj)� Signatur6l 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 4 1 Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date aA CITY OF CUPERTINO c) 2-1 r CUP TYOF O PERMIT APPLICATION FORM QP APN # Date: Building Address: Mailing Address (if different from building address): Owner'sName: Phon #: z oa - a Contractor: /� 7 // License 4: Contact: Phone: GWjO' 0-/�67�-Cupertino Business License#: 2601f Fax: uilding Permit Info: Bldg Elect ❑ Plumb ❑ Mech ❑ Job Description: Residential ACommercial ❑ S Ft, Floor Area: ze6t . 0 $/Sq.Ft.: � , i Cost o P ject. Occupancy Group: ,62ao Type of Construction: Please check this box if the project is a second-story addition: ❑ 11�Pro'ect Size: Standard ❑ Laze ❑ Major ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILER1 Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> 100K to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to IM 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 Elec Svcs 600V <— 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDINGS 1 of 3 2- J an CITY OF CUPERTINO Ir CITY OF 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 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 InstalUAlter 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> 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 BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Hearin MECHANICAL BREMRESAPP Remodel Res A liance ELECTRICAL 2of3 CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPEQ INO 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 Insection 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 I Planning Long Range Residential PLANNING ZADDCHG Address Change BUILDING 3 of 3