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03120122 CFPY OP GUPERTINO ��' BUILDING DIVISION PERMIT CONTRAC FOR INFORMATION BUILDING ADDRESS: PERMIT NOO 3120122 OWNER'S NAME: PERMIT ISSUE DATE 0E: SANITARY N0. CONTROL N0. ARCHITECT/ENGINEER: BUILDING PERMIT]] 0 BLDG ELECT PLUMB MECH Zop LICENSED CONTRACTOR'S DECLARATION O O O O Fp 1 hereby airthat 1 am licensed under provisions of Chapter 9(commencing Job Description <W with Section 10k))of Division 3 of the Business and Professions Code.and my licence is in full force Class effect. LiELECTRICAL UPGRADE 'F? Liccvc Class ca n F W Dalc CunTS ractor DELL ARCHITECTS DECLARATION ���® �a p #'d< 1 understand my plans shall W used as public records N WQ15\i kL JyU ; ED off Lwenmd Pnn nsfcsxial g OWNER-BUILDER DECLARATION APR 2 1 2004 <S. 1 hereby affirm that 1 am exempt from the Contractor's License Law for the MO o following reason.(Section 7031.5.Business and Professions Code:Any city or county K m� which requires a permit to ennswct,aleq improve,demolish,or repair any structureiy Prior n its issuance.also requires the applicant for such permit to rite a signed statement z< that he is licensed pursuant tothe pevisions(if the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area BUILM n YHS (commencing with Section 70)0)of Division 3 of the Business and Profusions Code)or Jut M is exempt therefrom and tW buu for the alleged exemption.Any violation of Section 1031.5 by any applicant for a permit subjects me applicant to a civil Penalty of 3"9�218'�.[9t4er0 0 Occupancy not more man eve hundred dollars(SS0B. P Y Type ❑1,as,owner of the property,Of my employee with wages as;their sole compensation, will do the work and the structure is not intended or.(rand for sale(Sec.1060,Business and Pmfexslonv Code:The Conoaclora Liave Law dots not apply w an owner of Required Inspections property who builds or improves thereon,and who doessuch work himself or through his own employccs,provided that such improvements are not intended or offered for sale.IL however,the building or improvement is mid within one year of compkdon,the owner- milder will Aare the Wrden of proving that he did not Wild or improve for purpose of sal.). 1 es uwrrer of Jte property,am exclusively contracting with licensed eonu¢tors to construct me project(Sec.10,14.Business and Profusions Code:)The Contractor's Li. rove Law docs not apply w an owner of property who Wilds or improve Ihemon,and who com uctsfor such projects with a conlnctor(s)licensed pursuant to the Contractors License Law. ❑lam eaem llltlu dcrlS.ec BAPCf Nis stall Owr�r _]]�� Dau 12 Z O WORKER'S COM ATION DECLARATI I hereby af0nn under penahy a perjury pate pf me f ing declarations: I have and will maintain a CeNEute of Covent to self-inxum for Worker scent s5iion.as Provided Tor by Section 37W of the labor Cade.for the performance of the work for which this New it is issued. 1 have and will maintain Worker's Comxu ion Insurance,as required by Section 3100 of me labor Code.for the performance of the work for which this permit is issued. My Worker's Compensation Insurance carrier and Policy number art: Cartier: Pal icy No.: _ CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not bo completed if IM permit is forone hundred dollars($100) or less.) I certify tha in the Performance of the work for which this Permit is issued.l shall not employ any person in any manner an is w become subject to the Workers Compensation Laws of Cal traitors.Date Applicant NOTICE TO APPLICANT:If,arm,making this Celli Rcau of Exemption,you should become suhject to the Worker's Compensation provisions of the Labor Cade,you must Z, forthwith comply with such provisions or this Permit shall be deemed mvaked. Z O CONSTRUCTION LENDING AGENCY j— � Ihereby affirm that there is a conswctinn lending agency for the performance or ^1 the work for which this Pemrir is issued(Sec.3091,Civ.CJ W Q Lender's Name G Under's Address U Q 1 mmly that 1 haus read this application and suer:that the above information is P: correct,i agree to comply with all city and county ordinances and au¢laws relating to 0U building eonsuuetion,and hereby aurhorim representatives of this city to enter upon the } ahovc-mentioned pmperty for inspection putrmics ))) gy (Wc)agree to save.indemnify and trcp harmless the City of Cupertino against / F' h liabilities,judgments.case and expenses which may in any way accme against said City / a(the pound ng of U ,z his Permit. APPLICgAffNffyyTel1V}NNDERSTANDSIAND WILL COt�sttPLY WITH ALL NrON-P91NT Issued by: Date SOUR`EG(1LATIONS.�\ ,y ,//- Re-roofs Sig m of A,limati Conhacmr r � /� Cat ' �J HAZARDOUS 4TERIALS DISCLOSURE Type of Roof Will the applicant pr fumm building occupant score or handle harutlal as declined by me Cupertino Municipal Code.Chapter 9.12,and the Health and Safety 0Code,Sectionor,25532(.)'l /f��(N`n All roofs shall be inspected prior to any roofing material being installed. Will the applicant orfuture building avxupam on equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove "WO haamdnus air contaminantsss defined by the Bay Arta Air QualityManagement all new materials.for inspection. Yes �Nu 1 have maJ the havrd/nus materials reyuimmenu under Chapter 6.95 of the Califnr nu Health K Safety Code.S¢tiuns 25505.25531 and25530.1 undcrsund thw ifthc building dors nm cureqdy have a l,am mat tt u my re nsmilay w naul'y IW occupant of the m'uncal vghicbustbrymctPro Its. oracerdreaeor, vancy. Signature of Applicant Date o rprapmoriscdagent All roof coverings to be Class "B" or better CITY OP CUPERTINO xsa .sw� 1sulLDrrvc DIVISION PERNO xCOI?I1 RAC=PORf1INP'.OIiMl 'N '.�M,,Au 7"4 � BUILDING ADDRESS: PERMIT"03120122 OW NER'S NAME: PERMIT ISSUE DATE AN KONTY) SANITARY NO. CONTROL NO. ARCHRMCrlENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 woo LICENSED CONTRACTOR'S DECLARATION Job Description Cd I hereby affirm that 1 am limnsed under previsions of Chap er 9(commencing with Section 70DO).f Division 3 of the Business and Professions Code.and my license is �„ mmBeclaanderr"` ELECTRICAL UPGRADE ,vn Dole sec class Contractor L F W DaIC Cu ARCHITECTS DECLARATION 1 understand my plain shall he usN az Public mentis it U 3 0� Licensed Pmressioml OWNER-BUILDER DECLARATION I I hereby affirm that I am exempt from the Contractor's License Law I'.,the O O following season.(Section]1D I.5,Businus and Professions Cade:Any city or county K m� which requires a permit or construct,almT,impmw,demolish.or repair any structure prior to its issuance.also require the applicant for such permit to file ardood statement < that be lalice.a.dpuseent1.the proviarenaef heContractor aLlano.law(Ch.ptcr9 Sy.Ft. Floor Area Valuation xN$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or y`<_ that he is exempt thamfmm and the basis far the alleged exemption.Any vialation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 39'�E18t"119tbCr00 Occupancy Type not mom than Fin hundred dollars($5W). # 0 1,as Owner of the property,or my employees with wages as Weir sole compensation, will do the work,and the structure is not intended or offered for sale(Sec.7044,Business and Professions Code:The Cortrecmra License law does not apply to an Owner of R Hired Inspections p,UdCny who builds or impmvu thereon,and who doessach work himselror through his Own employcu,provided that such improvements are not intended or offered for sole.If. however,the building or improvement is sold within one year or completion,the owner r builder will have Use burden of proving Nat he did not build or im Prove for purpose of sal.). I es owner of the property,am eaelusively contracting with licensed contractors to O ` construct the pmjea(Sec.7040,Business end Professions Code)The Commerce's U. came law docs not apply to an owner of property who builds or improves thereon,and who contracts for such projects with a contractor(s)Beamed!pursuant to the Contractor's License Law. of am exam I¢dclr/See. B h P C far azon Own_cr \ I.VN Date \7t/ WORKERS COM ATION DECLARATI I hereby affirm under penalty o perjury one of the f Ing declariumas: I have and will maintain a Certificate of Consent to self-insure for Worker's Compch. - 737V) on,u provided for by Section 37W of the labor Code.for the performance of the k for which this permit is issued. 1 have and will maintain Worker's Compensation Insurance,as required by Section of Ne Labor Code,for Ne performance of the work for which this permit is issued. Worker's Compensation Insurance carrier and Policy numlrer art: Caner. Policy NO.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE mads aced,,reed nm bu complered if the Permit is fornnc hundred dollars nI(NB less. 1 artily that in the performance of the work for which Nis permit is issued.I shall not employ any person in any manner so as to become subject to the Workcri Compensation Laws of California.Date Applicant NOTICE TO APPLICANT:If,after making this Cannes,.of Escmption,you should become subject to the Worker's Compemation provisions of the Labor Code,you must �Z fpnhwhh comply with such provisions or this Permit&hall ire deemed invoked. Z� CON SfRUCTI ON LENDING AGENCY I hereby affirm that there is a Construction lending agency l'ar the perfurmanec of LL' the work for which this pemana is issued Vac.3097,Civ.C.) D.1 Q Lendef'f Name az s Lender's Address U O L certify that 1 have read this application and state that the above information is 1t, correct.l agree to comply with all city and county on inanas and state laws relating to O U building construction,and hereby authorim mpreacnutiss of this city to enter upon the W above mentioned proper ty far inspection purposes. % CL (WC)agree to can,indent of Cy and kap harmless the City of Cupcni no against s lin liabilities,jed,ments.costs and Cataract which may in any way umbe..,.Iran said City U Z in conaequcnee of the grand ag Of this permit, t ^ APPLICA DERSTANDS AND WILL CON(PLY WITH ALL NON. IYT Issued by: Date //VV.•��K (( SOURCE G LATIS../` ^^ // I J 9� Re-roofs Sedw.f ApplicenUCOntracmr i Dam�— HAZARDOUS ATERIALS DISCLOSURE ( Type of Roof Will the applicant.,future building uccupam store.,handle harardo :material as defined by the Cupertino Municipal,Code.Chapter 9.12,and the Health and Safety Code.warren 2ss3z(an All roofs shall be inspected prior to an roofing material beim Installed. ❑yes �N. P P Y g P Will the applicant orfutu`rebuilding Occupant use equipment or devices whim If roof is installed without first obtaining an inspection,I agree to remove it hz uru nus air contaminants as defined by the nay Area Air Quality Management all new materials.for inspection. strict? ❑Yea AN. 1 have mad the hmaidnus mamaterials reyuimments under Chapter 6.95 of the Cali for nia Health ffi Safety Code,Sections 25505,35533 and 25534.1 undersumd that if Ne building dcea not arc tly M1um a tenant,thin it is my resOnnsihilitY to nntilY tic twtttpanl of Nc Cqulremen hiehmuat metprirdias.anenraccniBeaa:o(acumtey. Signature of Applicant Date 6 t IY z�� o fr.ra.tnenter]a,art All roof coverings to be Class "B" or better SvMCITY OF CUPERTINCO CUPEY°rFwo PERMIT APPLICATION FORM "O( N # Z- / 0-33 Date: Building Address: ►6lb1 oa ©A0 RMailing Address (if different from building address): 5 ��>� �rz. Owner's Name: Phone#: _ flLpt4 kDwz, `d b8-�I�Zb —,! StU4- Contractor: License #: �.15 �sTw�cJ'Cc�ly 55111 '9 Contact: ++ Phone: 4a�-6L6 aqq�} Cupertino Business License#: �C_AZ, VMAe fJCC Fax: Building Permit Info: -I-KStq�.c Qhqo F�AoRz'�G£uT L�GHTIN( ADD Twa 4k T 13oc�5, B �❑ Elect/ffN Plumb ❑ Mech ❑ Job Description: /�ii,�ir� q 1' Residential ❑ ial ❑ Sq.Ft. Floor Area: /SgTt.: Cost of Project: / Occupancy Gr p: Type of Construction: / Please check his box if the project is a /. second-story a ion: ❑ Quantity 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 <= l O00A ELECTRICAL BELEC1001 Elec 600V > IOOOA 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 1 of ��# -0 vm�ggA' QITY OF CUPERTINO* CITY OF PERMIT APPLICATION FORM CUPERTINO lift Quantity Fee ID Fee Description Fee Group BMITIGATR Res. Housing Mit Fee BUILDING BMNEWMULTI New Multi-Family Res MECHANICAL BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL BNEWMULTI Multifamily Res ELECTRICAL BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BNUMULTI New Multifamily Res 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 Repipe 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 HeaterNent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfrn MECHANICAL BRENLkMHAN A/C Units <= 10,000 cfin MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Fumace MECHANICAL BREMFURNOV Relo Fumace> 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 2 of 3 *ITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPEI�TINO Qua Fee ID Fee Description Fee Group I 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 BREMTHEATR Theatrical Ligbting 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 MPEFI FEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issuance PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING 3of3