04030194 CITY OF CUPERTINO �"""''
BUILDING DIVISION PERMIT �vC0NTRACT0R INFORMATION 1
BUILDINGADDRESS: PERMITNO.
04030194
'NEWS NAME: PERMIT LS5T1E DATE
PHONE: SANITARY WftOL NO.
ARCHITECrIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u00 LICENSED CONTRACTOR'S DECLARATION Job Description
C I hClam Nde
mby aral I am licensed under provisions of Chapter 9(Commencing ice„
b iNaon
Su ]WO)af Division Sof Ne Busimusand Professions Code.end mylianse"
^ n n full forte and effect.
5pi License Class Lie.g REVISION--ACCESS PKG/RESTRIPPING
Dam conuamr —NEW MIT ISSUED/ ORIG. #03120194
ARCHITECTS DECLARATION
1 understand my plans shall he used as public recorda
o u.
W Licensed Professional
G OWNER-BUILDER DECLARATION
<F I hereby affirm that I sm exempt from the Canuacme.License Law for the
DO following mason.(Section]ID 1.5,Business and Professions Cade:Any City nr County
K m which nsuifas•Permit m Construct,alcor.iepm,e,demolish,in repair any atmcmm
m-'^
prior in its issuance.also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuation $0
y11--0 (commencing with Section 7")of Division 3 of the Business and Professions Cnde)or
that M is exempt dmmfrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the appl¢aauo a Civil penalty of APN Number Occupancy Type
not n=Nen five hundred dollen
C]1.asowncr of the property,of my employees with wages u their sole compensation, 35917019 . 00
will do the work and the swats.is not intended or offered for sale(Sec.7W.Business
and Professions Code:The C.CmaCmr's License law does not apply m an Owner of Required Inspections
property who builds or improves thereon,and who doss suc h work himulf or through his
own employers.provided that such imp nvemer es tae notimended oroffecul for.We.If.
however.the building or improvement is sold within One year of completion,the owner.
builder will have the burden of pmving that he did not build or improve for purpose of /•
1,u nonce of the property an uclusivelydd crodeco is with licensed ed nshact et i S,
o e,La tree project(Sec.o in Business and Professions Code:)The Com inion.Li
emus law docs not apply je an owner of pmpertY who builds or improves Norton,ane -\
who contracts for such projects with a cantracmrtp licensed pursuant m the Contnetors
Licensen.Law.
❑lander gee. .B&P3Cfy.[r�.thCiasy/ryw
er
WORKE Date
/B'3 ENSATION DECLAR N
_ reby en'mm undf na y of peejury ane of the fol dedueliom:
❑I love and will maintain a Cenifsum of Catuent to self insure for Workcr'sCompen-
nuon,as provided for by Studio.3700 of the labor Code,for the performance or Om
work for which on,permit is issued.
1 hove and will maintain Worker's Compensation Insurance,as retrumd by Section
3700 of the labor Code,for the performance or the wort for which this Permit is issued.
My Workers Compensation Insurance carrier and Policy number art:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section used not W completed lithe Permit is formic hundred dollars($100)
or Ices)
I cenify that in the perfmmuna of use work for which this psomdd 4 issued,I shill not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT.If,after making this Certificate of Exception,you should
become subjtut to me Worker's Compcasauon provisions of Be tabor Cade,you most
.,O furthwlth Comply with such provisions Of Nis permit shall be caned revoked.
z .~N.. CONSTRUCTION LENDING AGENCY
Er I hereby aXimn char Nem iso construction lending agency lir she performance of
[�
the wore for which this Permit is issued(Sec.3097.Civ.C.)
t[] 0Leddcr's None
G lenders Address
V Q 1 certify that I have read this application and sum the the thew iofomt.in.is
ly — CmCCL 1 agree to Comply wish all City and county ordinances and stale laws relating to
OU building construction,and hereby authorise representatives of this city to cnmr upon dm
}[Ll shove mentioned property for inspection purposes
a
(We)agree to save,indemnify and keep harmless Be CAY of Cupcnim against
U Z inconseque consequence
of
hecosuang or this
may in any wry accmc against said City
V z A APPLICANT
or UNDERSTANDS
of Nis per mit 1
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALy NON-p0NT Issued by: Date
SOURCE E ULATIONS. 3//G�.c�J-!1/
Re-roofs
Signet OTAPplicantrCon or Dem
HAZA ATgotc.p DISCLOSURE Type of Roof
WillytheCupentur Mum buildinge.0 Capt atom nr rend le the Health b.and Safety
nd
az defined by the Cupertino Munitipal Code.Chapter 9.12,and the Health and Safety
" [3c.Section 25532007 All roofs shall be inspected prior to any roofing material being installed.
Yes 0
Will the applicant or future building oaupam use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit harardnus air contaminants a defined by the Bay Arca Air Quality Management all new materials for inspection.
D'utrin7
❑Ys
1 have maJ the hvsNnus materials requirements under Clupter 695 of the Califor.
ria Heal"Safety Code,sections 25515,25533 and 25534.1 understand that if the Wilding
does not currently have a Writs,that it is my reaponsibility,in noufy the on'eupanl of the
icgaiemcnts which tau be met prior m issu cora cemrlcam of up c. Signature Of Applicant Date
Ow r .moa><aase.t ,m All roof coverings to be Class"B"or better
CITY OF CUPERTINOBUILDING DIVISION PPRMI0 X0N.TRkCT0R,INF0 T "'M K
BUILDINGADDRESS: PERMIT N0.(]4(]3 019 4 .
PERMIT PsUE DATE
OWNER'S NAME:
LONG'
SANITARY QAtOL NO.
NE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
C= 0
yaZ
LICENSED CONTRACTOR'S DECLARATION
00 lob Description
s�� I hcmhy affirm that 1 am licensed under provisions of Chapter 9(commencing
with Sceion]00o)nf DivisionJof NC Businessand Prufcssians Codc.and myli¢nu ix
mfail mmaand.rr"` REVISION--ACCESS PKG/RESTRIPPING
Z-i Data License Class CounA
'l- Data c^^l�or NO NEW PERMIT ISSUED/ ORIG. #03120194
W ARCHfrECTS DECLARATION
�a I understand my plans shall be used as public records
ikw
u I-„ Licensed Professional
OWNER-BUILDER DEC.Cmadr ON
I masa affirm Thal 11. ,Bump..Dom the oesins Co License Law for he
p O following mason.Section 703 1.5,Business and Professions Code:Any tiny or county
Q_ which requires a Permit in Construct
elms improve.demolish,w repair any structure
prior m its issuance.also requires the applicant forsuch Permit to file a signed summent Valuation
'�< Nat he is licensed prdandrlta de pmvisiou of the Combeim's License Law(Chapur9LE3
q. F[.Floor Area $0
pH$ (commencing with Section]OBD)uf Division lnf Ne Businr.•and Profusions Cn�e)w
i - Nat he is ergs l dba 0.m and Ne basis for Ne alleged ascription.Any violation of
Secdon]OII.3 by eny appliau"for a pandit subjects Ne olipluall m.civil pcnahy ofAPN Number Occupancy Type
nut more Nan five handled dolls..(5500).
❑I,M owner of the Propcny,or my employees with wages u their sole mmpedsa0oo, CJ AE
17 0 19 0 0
will do the work,and Me sweum is nos intended or offered for sale(Sea]044,Business Required Inspections
and Professions Code:The Convector's License law does not apply to an owner of q P
property who builds or improves thenen,and whodoessuch work himselfor Muough his
own employees,provided that such improvements an non intended or offered pustule.If.
however,the building or improvement is sold within one year of completion,Ne owner.
builder will have the burden of proving Out he did not build or improve for purpose of
sale.).
Xo n
1,u owner of Ne property.am Meloavalr convecting with licensed comncmLn w
mcl the project(Sec.7044,Business and Professions Code:)The Contractor's Li.
cense law docs not apply to an owner of property who bai Ids or improves Nedion,and
who contracts for such projects with a conuacmr(s)licensed pursuant to the G^nmailm"
License Law. -
❑1 am Maid I under Sec B d:P C for this Mon
Owner oath-�
WORKE1B'S ENSATIONDECLAR6T�OONN n
Rn
hereby anunta do ey of pad.,oa of Ne fol isfg dalauou:
I haw and will maintain a CeWd cam of Consent to self-insure re
for Worker's Comped.
satin..,M provided for by Section 3]00 of the labor Code.for Ne Pafomuna of Ne
work for which this permit is issued.
❑I have and will maintain Workers Compensation Insurance,u required by Sano..
J]00 df the labor Code.for Ne performance of Ne work for which this permit is issued.
My Workers Compensation Inxunnce carrier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEM PION FROM WORKERS
COMPENSATION INSURANCE
(Thu section need not be completed if the Permit is intone hundred dollars(5 100)
re los.)
I eemfy Nan in Me perform.....of Ne work for which this permit is issued,I shall not
employ any Person in any manner so as in become subject o the Workers Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IL after making Ma Ccnincam of Ecmnption,you should
become subject no Ne Worker's Compensation provisions of the labor Calk,you must
J 2 ra"with comply with such Provisions or this permit hall be deemed rtv.kcd.
z O CONSTRUCTION LENDING AGENCY
(-+ Ih.leby aRrm Met Men is a construction lending agency for the Performance of
ai> the wurk for which this permit is issued(Sec.3097,Civ.C.)
W Q Lcmlcea Name
a Under's Addmu
U 0 1 candy than I have read this application and sum that Me above infomutiun is
W P covert 1 agree M comply with all city and county ordinances and stale laws dilating no
C building construction,and hereby euohnim representatives of Nis city M enter upon the
r~W ahow.mcntiuned propeny for inspection purposes.
Flu 0. (We)agm,no save,indemnify and kap handless the City of Cupm
cno against
I,I liabilities.judgments,Cosa and expenses which may in any way scene against said City
Uz intoan,minceorMegraming^fthisPe.i,, Date
^' APPLICANT UNDERSTANDS AND WILL COMPLY WITH AI.{!NON-e DINT Issued by:
SOURCE E ULATIONS. (/'7
Re-roofs
Sigw of Applic t!Conv or Data HAZA 0 ATERIALSDISCLOSURE Type of Roof
Will the applieam or lure building Occupant store or handle hazardous material
as defined by the Cupertino Municipal Codc.Chapter 9.11,and the Health and Safety
Cale.Section 15532(.)? ��t /// All roofs shall be inspected prior to any roofing material being installed.
0 Yes "
Will the applicant or future building occupant uta equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
.mit hazardous air contaminants M defined by the Bay Area Air Quality Managemcrn all new materials for Inspection.
DSvics?
❑Yes
[have read Mc haardlms matcrialsrtyuimmcnts under ChaPmr 6.95 of Nc Califon
nia Heslth&SofcnyCod.,Sadou255D5.255J3 and255J4.[umicrsund thairi a huilding
docs not currently have a tenant Nat it is my mspo adality M notify the occupant of Me
requirements her nn be men priermiMe enracetdw.m.rggnP Signature of Applicant Date
ow r ntherivadagent am All roof coverings to be Class "B"or better
CITY OF CUPERTINO
m 1 of 1 PERMIT RECEIPT OPERATOR: conniew
COPY # 3
Sec : Twp : Rng : Sub: Blk: Lot :
APN . . . . . . . . : 35917019 . 00
DATE ISSUED. . . . . . . : 03/22/2004
RECEIPT 4 . . . . . . . . . : 24913
REFERENCE ID # . . . : 04030194
SITE ADDRESS . . . . . : 10455 S DE ANZA BLVD
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : LONG' S DRUGS
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95015-1389
RECEIVED FROM . . . . : HARRY JEW
CONTRACTOR . . . . . . . : LIC #
COMPANY . . . . . . . . . . :
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
TELEPHONE . . . . . . . . :
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
-------- -- - -- - - -------- ----- ----- ---------- ---------- -- -- ---
BPLANCKREP HOURS 4 . 00 222 . 00 0 . 00 222 . 00 0 . 00
TOTAL PERMIT 222 . 00 0 . 00 222 . 00 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
------ - - --------- ------------ ------- ---------- -
OTHER 222 . 00 VISA
TOTAL RECEIPT 222 . 00
CITY OF CUPERTINO
0m 1 of 1 PERMIT RECEIPT OPERATOR: conniew
COPY # 4
Sec : Twp : Rng: Sub: Blk: Lot :
APN . . . . . . . . : 35917019 . 00
DATE ISSUED. . . . . . . : 03/22/2004
RECEIPT # . . . . . . . . . : 24913
REFERENCE ID # . . . : 04030194
SITE ADDRESS . . . . . : 10455 S DE ANZA BLVD
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : LONG' S DRUGS
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95015-1389
RECEIVED FROM . . . . : HARRY JEW
CONTRACTOR . . . . . . . : LIC # .
COMPANY . . . . . . . . . . :
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . . ,
0 TELEPHONE .. . . . . . . . :
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---- -- ---- ------------- - - ------- ------ ------- - - - --------- - ------- ---
BPLANCKREP HOURS 4 . 00 222 . 00 0 . 00 222 . 00 0 . 00
---------- ------ ---- -------- - - ------ ----
TOTAL PERMIT 222 . 00 0 . 00 222 . 00 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- - ----------- --- ---
OTHER 222 . 00 VISA
TOTAL RECEIPT 222 . 00
*ITY OF CUPERTINO+ 2-6�/ 7
CITY OF PERMIT APPLICATION FORM
CUPE TING
APN #3S t7
6 / Date:
Buildingress: Mailing Address (if different fro g buildi address):
6 de
Owner's Names: Phone #: 925 R79
Contractor. p License #:
Contact: Phone: 79 3(o Cupertino Business License#:
Fax: 0,6873
Build Permit Info:
BId L] Elect ❑ Plumb ❑ Mech ❑
Job Description: G `
Residential ❑ comer iac�l—(]
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: Occupancy Group:
Type of Construction: Please check this box if the project is a
second-story addition: ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 1 OOK to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> IM to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax –Resi/Mobile BUILDING
BELEC1000 Elec 600V <= IOOOA ELECTRICAL
BELEC1001 Elec 600V > 1000A ELECTRICAL
BELEC200 Elec Svcs 600V <= 200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
1 of ) —�
SO 46ITY OF CUPERTINO 10
CITY OF PERMIT APPLICATION FORM
CUPERTINO
Quantity Fee ID Fee Description Fee Group
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BOVERTIME Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE Pblg Fixture PLUMBING
BPGAS Gas Piping System Fee PLUMBING
BPINTERCEP Ind Waste Interceptor PLUMBING
BPLANCHK Plan Check Fee BUILDING
BPLANCKADD Plan Check Add Multi BUILDING
BPLANCKREP Plan Check Repeat Fee BUILDING
BPREPIPE Re i e Of Fixtures PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BPSEWER Sewers PLUMBING
BPSPRINK Lawn S rinkler/Backflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain &Vent PLUMBING
BPWATER Install/Alter Water Pie PLUMBING
BPWHEATER Water Heater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit > 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10,000 c$n MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BRENU URNOV 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 Signs, Marquee ELECTRICAL
2 of 3
( (C - `CITY OF CUPERTIN*
CITY OF PERMIT APPLICATION FORM
CUPERTINO
Quantity Fee ID Fee Description Fee Group
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
ZADDCHG Address Chane BUILDING
•
3 of 3
C - `°CITY OF CUPERTINOS 3( Zo o
CITY of PERMIT APPLICATION FORM
CUPEII;TINO
11- 24 -03
'qwAPN # �- I l I Date: 12- 12 - o3
Building Address: Mailin Address (if different from building address):
l O tiSSr e .4 Hzc t31vd. Cu er ;
Owner's,N� e: Phone #:
o� s " �� 5-}ores S, c . 92S- 2s6 - o6CC
Contractor: License#:
Er;c F Akd¢r e,A TKc . 3- O 825yo
"ntact:A Phone: 5"'U- VO-901 Cupertino Business License#:
VO&A rt&,olerc,o - Cry. "W'F'ax:5_/0-q3o-2S6I
Building Permit Info: -71 S-61 B`I
Bld E1 Plu(0jrt�j-) Me
JobDescription: T.T. wk',or T_ew
Residential O Commercial New s Le I v; ti
Sq.Ft. Floor Area: 3 I q9s 5� P , $/Sq.Ft.:
Cost of Project Occupancy G up:
_� t So 000
Type of Construction: fPteaSe chec this box if the pr Iect is a
d-sto dition: ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1 M 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 BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
lof3 ��0� / 2/