04030135 CITY OF CUPERTINO �
BUILDING DIVISION PERMIT CONTRACTnRINFOMATION�, ,
BUILDING ADDRESS: PERMIT NO04030135 4p3p135
R'S NAME: PERMIT ISSUE DATE
NE: SANITARYO. OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LOO LICENSED CON'rItACTOR'S DECLARATION Job h
w❑ I thereby allirm ND
et I em licensed under provisions of Chapter 9(commencinggt2itI6 /r
ra w with Section 70I10)of Division 3 Of Me Busouss ad Profoadma Code,and my license is Y t9 " 66% {�®
._may in mu force and eff«L
DMZ LiennmClass Lic.' 81 FENCE
Date ContrAmol ARCHrrECTS DECLARATION ��� 2 04
WI understand my plans shot]W used As public mcords
3p3 Licensed Pmfcssional 13Aet'IL®Ip.a,a
OWNER-BUILDER DECLARATION ''��YY tltlR�A.
f I hereby affirm Nat 1 am exempt from the Contractors License Law for the
00 following reason.(Section 7((31.5,Business and Professions Code:Any city Or County
3 whici requires a permit to construct.alter,improv,demolish,or repair any structure
Fiy Prions its issuance,also requires the applicantfor such permit to Ole a signed statement 600
Z
< Mat hculicensed pursuant to provision ofMe,Common's License hw(Chaprer 9 Sq.Ft. Floor Area Valuators
(commencing with Section 70001 of Division 3 of the Business and Profusions Code)or
i $ that he is tromps therefrom and the hues fen the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit svbjecu the applicanuo a civil Penalty of 3 perp p . Occupancy Type
not more Nan Ess hundred dollars(5500). -
❑1,As owner of Ne property or my employees with wages As their sok compensation,
will do Ne work.end theawerure is not intended mannered formic(Sce.7064,8 dneu
and Professions Code:The Contractors License law does not appy W An owner of Required Inspections
propeny who Wilds.,unproves thromm.and wnodoesauch.bkhimselfo,d mu'h his
own employers,provided Nat such improvements Am not intended oronered for We.If,
however,Ne building or improvement is sold within one year of Completion.Ne owner.
builder will ban Ne burden of proving that he did not Wild or improve far purpwe.of
We.).
0 1,As owner Of the property,am exclusively contracting with licensed contraction An
Common the project(Sec.7044,Business and Profusions Code:)no Comba oca's Li.
cense law does not apply to an owner of property who Wilda or improver ncecreon,and.
who contracts for such projects with a con.mmgs)licensed pursuant to dW Contractors
lCan ucmpt and sec. ,B&PCfor Nu mason
OMPENSATION DECLARA N
I booby affirm under penalty of perjury Cate of the following dularetiou:
I hove and will maintain,CerufiuLA or Consent w mfr-insure For WmkArs Cmmpcn-
safion,u provided fm by Section 37W of the labor Code,for the performance of the
work for which Nis permit is iuucd.
❑1 ban and will maintain Worker's Compenerown Insurance,u mquimd by Section
37W of the labor Code,for the pmfoamance or dW work for which this permit is issued.
My Workers Compensation Insurance Cartier and Policy number H:
Cartier. Poliry No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section nand not W completed if tW permit is formic hundred dollars($HAH
ar los.)
1 certify that in Ne performance of Ne work for which this Permit is issued,l shall not
employ any person in any manner m As to become subject to she Workers'Compensation
Laws of c.liforni..D.
Applicant
NOTICE TO APPLiCANf:IL her making this Cenificate of Exemption,you should
become subject w the Workers Compensation previsions of the labor Codc,you must
,J ,z forthwith comply with such provisions or this Permit shall be deemed revoked.
z CONSTRUCTION LENDING AGENCY
'c.L IWmby affirm Met there is a consuucuon lending agency for the performance of
C
to work for which this permit u issued(Scc.3W7,Civ.C.)
f31 A Lender's Name
z Lender's Address
U O 1 cenify that I have mad this application and SLAW that the above information is
t" correct.I agree w comply with all city and county on irwNes and sate laws relating to
O U Wilding Construction,and hereby authorim mpresenatives of this city to enter upon Me
r� abovcmendoned Property Tor inspection purposes.
F+gy (We)Agree m cave,indemnify and keep harmless the City of Cupenuo against
N li
la.col.And C.,sea which may in any way secure against said City
U mcouequne.of 'rami.,of Nis Permit. / \l
APPLICANT UN ERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU RE TIONS. f
_ ✓Z Re-roofs
to c o 'c
HAZARDOUS MATERIALS DISCLOSURE Date Type of Roof
Will the applicant m future W ildin,occupant room or handle ha antow material
As defined by the Cupenino Municipal Code.Chapter 9.12,and the Health and Safety
Aftme,Section 23532(6)7 All roofs shall be inspected prior to an roofing material bei.
❑Yea [3+f6 P P Y g g installed.
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
v� it hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
tricR r7axr
❑Yes Y
I have mad cite haurdous materialsmquiremems under Chapter6.95 offt Califon
SxfctyCodc,Soeuons 25505.25533 and 25534.1 undetaand Maifttr Wilding
Jou am c mlythave,Wnent Nat is u my mspouibility w rwtiy tic acuPant of tW
reyui n tchmu Waretprimrwirsuatmemracen;rmaa�c � / Signature of Applicant Date
er or authorimd agent D= All roof coverings to be Class"B" or better
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FENCE APPROVAL
CITY OF
CUPFI�T1N0
Community Development Department 10300 Torre Avenue Cupertino, CA 95014 (408) 777-3.30f
3
(DATE)
I am an adjoining property owner of (/to ,C /y iy td o �l
/' (NAME)
whose property is located at 816 -51 �a 7rc n we0/1 to —
(ADDRESS)
I approve (as per Ordinance No. 686, Section 16.28.040 .of the Cupertino
Municipal Code) the allowance of a 9 f� foot high fence facing
(8 FT. MAXIMUM)
my property.
C, OpFFEE CUR
SIGNED: NAME: /l
ADDRESS:
ly
RM 0'"%R FAVE D
b
x;r MAIFNfJOW6 6 cca l
,;�CITY-OF CUPERTINO
BUILDING DEPARTMENT
FENCE APPROV
• AL
CITY Of
CUPFI�i'.1N0
Community Development Department 10300 Torre Avenue Cupertino, CA 95014 (408) 777-3308
RECEIVEOLO)"
MAR 15 204
CITY OF CUPERTINO 2 /zt/ o �/
BUILDING DEPARTMENT (DATE)
I am an adjoining property owner of �o cJ '2 i✓i eo rJ
(NAME)
whose property is located at ea s" C6�oh weoC/ A,
(ADDRESS)
I approve (as per Ordinance No. 686, Section 16.28.040 of the Cupertino
SMunicipal Code) the allowance of a a -- foot high fence facing
(8 FT. MAXIMUM)������ V E
my property.
SIGNED: NAME:
ADDRESS:
J 4-n C9001)
777 - 2 721
`CCy *ITY OF CUPERTINO*
CITY OF PERMIT APPLICATION FORM
CUPEkTINO
APN # 3 / / Date:
6 O
Building Address: Mailing Addres (if dif rent fro building address):
O S 6o"mac r`
O 's Name: Phone#:
/ 3�0 �1 257- y t/
Contractor: - License #:
Contact: Phone: Cupertino Business License#:
Fax:
Bui ding ermit Info:
Bid Elect ❑ Plumb ❑ Mech ❑
Jobscriptio •
/
Residential f--]
Sq.Ft. Floor Area: Y /Sq.Ft.:
Cost of Project: 9616 /\_v Occupancy Group:
Type of Construction: Please check this box if the project is a
second-story addition: ❑
Quantity--T Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> I OOK 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 <= IOOOA ELECTRICAL
BELEC1001 Elec 600V > IOOOA ELECTRICAL
BELEC200 Elec Svcs 600V <= 200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Inve,, ation fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
2� 7 � /"
lof3 � Qi` vz�—
(auba WITY OF CUPERTINO
CUP kTCITY OF
O PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
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 cf n 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 Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Sips, Marquee ELECTRICAL
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*CITY OF CUPERTIN40
CITY OF PERMIT APPLICATION FORM "
CUPERTINO
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 Insection BUILDING
BSW1M 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 Mecb Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
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