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03090046 CITY OF CUPER'1'INO `" !. rad-,dz ;•'*x oma '`• �: DUILDING DIVISION PERMIT aCONT4UCCTORiINFORMATION f a BU DOING ADDRESS: "'A"" NOO 3 0 9 0 04 6 W NER'S NAME: PERMIT ISSUE DATE NE: SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH +00 LICENSED CONTRACnOR'SDECLARATION JobDescri tion I hereby affirm that 1 em licensed under provisions neChode. 9(commencing p in fa Seniu ) McDivixionJ of NC Bus�cuand Profcuinns Codc,and myliccnu is 4 infullfor ffcct / �31gG SERVICE UPGRADE �'� Z License C � A Lie.p FI N A� p Oalc��a�Curs for k_y IJ' a " tiJ ARCHITECTS RATIO �— C-i Ion rsts pia shall uSed liertcod, SEs '1003 >au tr L Licensed Pmfa.giV 1SO - . <g H OWNER-BUILDER DECLARATION a�I��s`+- p o - I herchy atirm Ihm 1 am exempt from the Contractor's License Low I'or the B��Ig�M following M0mm.(Senium 7033.5,Business and Professions Code:Any city.,county "Y <m� which requires a permit tel cnnswet,elhcq improve,demolish.or repair any structure CzAnn - Cni prior at its issunnec,also requires he applicant(orsuch wMiLto Glc a Signedautcmcnl < that he is licensed pursuant to the pravisionsof the Contractor's License Law(Chapter Y Sq. F[. Floor Area Valuation (commencing with Section 7")of Division of the Business and Professiom Conic)or Net Ile is exempt therefrom and she basis for Ire alleged esarrinme.Any viO1a4n of 3162 9069 . 00 Section 70)1,5 by any applicant for a pemnit S.bjects She applicant to a civil penalty of APN Number Occupancy Type not more man five hundred dollen($500). - ' -- --- I,a owner of the propend,or my employees with wages AS their sole compensation, pT �ty'-��,+p�[[[/��]]]7555�,,,i��7``` will do the work,and me swauu is not intended or.ffmd for sale(Sec. Business - H ('ECgtllre9`fY15 O5 and Professions Codc:The Contractor.Limos Lew does not apply to an owner of g Li property who build&or improves hereon.and who does such work himselfor through his 501 - FINAL ELECTRILAL ENERGY own employee,provided mat such improvements Are not intended or offered for sale.if, - SOS - FINAL ELECTRICAL however,the building or imprvement is Sold within one you of completion,he owner builder will have tbe burden of proving that he did ant build m improve for purpose of SAM). - El 1,as owner of the propend,em exclusively contracting with licensed contractors to - - Construct he project(Sec.7044.Business and Professions Cade)The Conlracfer's Li. came Law does not apply to an Owner of property who builds or improves hereon,and who contracts for such pmjects with a etrtnctor(s)licensed pursuant o the ConmctoM1 License Lew. ❑I am eaempl under Sec. B k P C for this mason nen Data WORKER'S COMPENSATION DECLARATION I hereby affirm under pe rally or perjury ow of the following declaredons: 1 ban and will maintain a Ceni0este of Consent o Se1f.inaure for Worker.Compton. ,.lion,aY provided for by Section 3700 of the Labor Code,for the performance of me work for which bis poroth is issued. ❑I have and will maintain Worker's Compensation Insunnce,as required by Section 3700 of the Labor Code,for he performance of the work far which this permit is issued. My Worker's Compensation Insurance carrier and Policy number art: Cartier. Polity No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE' (This Section Iced not be completed iftbe permit is for one hundred defian131ro) or less.) I Comfy that in the perramtance of the work for which this permll is issued,1 shell not emPiny C y in any manner so as to become subject the Wcrkere Compensation Laws of Ce, A.Dau Apylicanl. NQTJRE T PLI cr making Nis Cenilcale of Exemption,you Should FE-do s Joel o the W er's Compensation previsions of the LAW Cade,you most 0 vZ nfwidl comply with such provisions or this permit shallbe deemed revoked. Z O CONSTRUCTION LENDING AGENCY I heuby affirm that there is convection lending agency Icor the performance of YI > he.,it for which this permit is issued(Sec.3097,Civ.C.) 'y A Lenders Name Z Lender's Address J 0 1 cenify bat 1 have read this application and slaw mu me above infmoulLon is E-' building 1 agree ct comply hera all oily and county ordinances aimof end sou laws raring e U building conswction,and ferry wlhorinrtoses. utives of hiuitymenlu upon me 1 alavo me el,agree property(Miimpaction add keep ha. (s ju ogre to cove,indemnify end keep harmless the City or against id Ci ky rpt liabllides,judgments,co,u and expense which may in any way acerae gains said City on his Permit. J APPLICANT Of Eg STANDS morip,of IAND WILL COMPLY WITH.[.LL_NON-POINT Issued by: Date SOURCE RE ON . ✓�/ Y�-'O Re-roofs Si Iurt deplicanVContr mr Data HAZA DOUS MATERIALS DISCLOSURE Type of Roof Will he applicant or future building aecupanm store or handle UUMdoas material As defused by the Cupertino Municipal Cade.Chapter 9.11,and he Heath and Safety da.otYas ss31(a)+ [/$,}.' All roofs shall be inspected prior to any roofing material being installed. Will the aPPlicgot or Rl building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove 1401ilt hazardous air contaminanu as defined by the Bay Arca Air Quality Management all new materials for inspection. trict? p Yes No Ilew mad he Meudlmsmvuriab requirements under .Chapter Ii.95 of the Califon tie Hwlth&SafclyCo4.Sections 15505,M577 and 255]4.1 underhand Chat it the building d not cu tly h in a umnL Chet iI is my rexponsihility r notify the occupant of the vimma hicm..bemclpdm ix...C.r.cenlgcauo0ecap y Signature of Applicant Date wmer nrVKWd egetl' Pal All roof coverings to be Class "B" or better CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPEkTINO APN# / i Date: �D � O Building Address: 10-?9y � C4 e, Cq. Owner's Name: h e# ^ 2-7/2 a Contractor: License #: - a- CIL=Z (o3( 01 (p Contact: Cupertino Business License#: " 7L_ W rmit Info: Ele_ct Plumb ❑ Mech ❑tion: p' Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Pr ect: Occupancy Group -� FCO. Type of onstru • ut Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILERI Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> l 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> I OOOA 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 3 CITY OF CUPERTINO g o PERMIT APPLICATION FORM CUPERTINO Quantity Fee ID Fee Description Fee Group BMITIGATR Res. Housing Mit Fee BUILDING BMNEWNE LTI 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 BNUSFD New Single Family Res BUILDING 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 rinklerBackflo 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 cfm MECHANICAL BREMAIRHAN A/C Units<= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREM 3USWAY 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 2of3 a CITY OF CUPERTINO CUP One PERMIT APPLICATION FORM QuantityFee ID Fee Description Fee Group 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 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 Ins" ection BUILDING BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS ., .Temp Dist Svcs ELECTRICAL BUSLIC :::';.,..Business License BUILDING ELECTRIC T0.'Electrical sq foot ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE PlumbingPermit Issuance PLUMBING PPLBG PlumbingFees foot PLUMBING ZADDCHG Address Chane BUILDING 1 3 of 3