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05120011zzC .. F yC az UO` V �a UZ CITY OF CUPERTINO- BUILDINGDIVISION PERMIT ,CUNTR,A-C';�.I;��'U.�I .xaTM�'N BUILDING ADDRESS: PERMIT Nil. 05120011 1164 nR OWNER'S NAME: PERMIT ISSUE DAIS YURIY PRAGIN NE: SANITARY NO. CONTROL NO. ARCHIISCT/FNGINEER: BUILDING PERMIT INFO BLDG. ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description 1 hereby affirm that I Am Reacted under pmviYau of oommor 9 (emmeOcing P wish Section 70(11) of Division 3 of the Business and Professions Code. and my license is in fell fume and effect. UPGRADE ELECT. PANEL (200AMP) License Class Lk.I Dem Contractor AR mail be. TS DECLARATION ECL 1 undenund my .lull be used ss rteord. ' ^�� Pines public �f Licenced Professional OWNER -BUILDER DECLARATION 1 hemby alarm that I em exempt from she Conuactoea License Law for Om fallowing reason. (Section 7031.5, Business and Professions Code: Any city at county which mquhw a permit m construct, Wm, improve. demallad. As mpnir any stmcen, $1200 prior An its issuance, also mquiroa the applicant for such permit to Ole a signed aummem Sq. Ft. Floor Area a OBtion that he is licensed puranant m the provisions or On Cnuutues uce"e Law (chapter 9 1i (commencing wish Section 7000) of Division 3 of the Business and Prefaalons Cade) At �N/N that he Is exempt Aluminum and the hub for she allgcd eumptihn Any violW6n of Section4"permit subjecu she apPilcut m a dMl Penalty or e more naadldcant for P Occupancy TI pe does ❑ 1,u neareroftheproperty, w myuuployces wide wgnudse4 sum camPewdn. ns Re aired Iections - willdoshework,andsheswcmmbnmiaWndcdwoRmeAfw We(Sm.ID .BLWmW and Ptorevlooe Cade: The Canuscmes Limes LAW dean Am. Apply m an owner of q P Propene who builds w improves thereon, and who doesmuch work Massif ar dough his Am employees, provided that such Impnewmeno m not Intended aroRemd forsale. B. Ammons. the building orhnprovemcm is mid within sae year of cempledon. the caner - builder will have the burden of proving that he did not build As Impmw for purpose of 7ole 1, u owner of the property. Am excluiwly conbaain6 with licensed commemn to construct the pmjcm (See. 7044. Business W Profession Cade:) The Commences Li- cense Law does not appy An an oma of prapmYwhc builds ar improve theren, and, who commcu for such pm)eaa with a conlnctads) How sed pursuant m the Contr.emr's Lleenm IAw ❑Imo ponder See .Bl PCr Nb a Ow Dau Q� KER COM A N DECI.AMTION I hereby &farm under penshy f :'jury aro of W folknving declaruins: I love And will maintain • Cartllicuaf Came. An elf-Inwre for Whether.Compel- ssdhn, u provided for by Sudon 3700 of she labor Code, f" da performance of the wort for which this permit u issued. ❑ 1 have and will maintain Workers Compensation Insurance, u required by Section 3700 of the Wor Cade. for she performers of the wk for which this permit As Issued. ' My Workers Compemation Insurance carrier and Policy number am: Carrier. Polley No.: CERTIFICATE OF EXEMP IKIN FROM WORKERS' COMPENSATION INSURANCE rndaseNn reed ntbocamplesed U the permit is foronhundred Wars(3100) or mss.) I xenify that in dm performance of dm work w which rob permit is harmed. I shall am omploymy punch in my mune'. osebjecua thewark:recompensmon Laws of California. Dam Applicant NOTICE TO APPLICANT. If, after making this Certiflate of Exemption, you should become subject nc the Worker, Compensadon provisions of the Labor Code, you most farthwith comply with such provisions As tide permit shall be deemed revoked, CONSTRUCTION LENDING AGENCY I hereby AErm the them In a cotnuucdon lending.geecy for the perfameum of she meth for which this permit b noted (Sec. 3097. CN. C.) ' Lendees None Lendees Add. I c.rdly that I have rend this application and mate the the above informative is . conal. I agree An empty with all city and county hNlnenca and mu lam relaing An building construction. and hereby mthadse reposums0vea of shi. city to enmtupnn the above-mendotmd property for lmpection purpwet (Wal) agree to saw, indemnify and keep bunions tin City of CuKr ino Noult ' Imbilides, judgments, coast and eap eAAA which may In my my ucroc agaims said city In cc nee o[ the gran' of this Permit. APP ANT &NDERST S AND WILL COMPLY WITH ALL N -Poll ued by: Date no / O Re -roofs Type of Roof ' hfAWcaroucausnem, ATERIALS DISCLOSURE Ua Will lhcapplicm As fu truing occupant short "handle luxurious mamdal u defined by the Cupatin uui pal Code. mapmr 9.12. and the Health and Safety ode. Section 25532(a)7 All roofs shall be inspected to any roofing material being installed. ❑Sen ONO prior If a roof Is installed without first obtaining an inspection, I agree to remove Will tM applicant or future building Occupant um equipmnt or devise which emit buaNnus Air contaminants As dcflncd by the Bay Area Air Quallty Management all new materials for inspection. Diwta7 ❑Sen ON. I haw mad she haorthusm,terlals requhemcsundo CMpmri95 orthe Califor- Cade. Seed 23503,23333am125534.1.Mkmuddmifde bdlding -.w a eau u 1A b m Iniity m nufy tiro eecupant or the mpb 1 r .Ccrdruamof0avpomy. aed.;cm Signature of Applicant Date .. All roof coverings to be Class "B" or better Dam v L Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Buildine Department JOB ADDRESS: ll (, g r4. co 9,5VI PERMIT # s Z d of / OWNER'S N cIR i Q�, -rr-Mq era_ i PHONE # O GENERAL CONTRACTOR' f e/d f Age ✓ FAX # I am not using any subcontractors: l hmzl;-. �02 Oat Signat Date Please check a licable subcontractors and com let a followin information Owner/ Contractor Signature Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical A VP CJoallv-, c,- 'iExcavation Excavation Fencing Flooring: Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/ Contractor Signature Date IN CITY OF CUPERTINO PERMIT APPLICATION FORM N# 3&A oq 0%/ Date: 121020SS uilding Address: Mailing Address (if different from building address): 1162�t Owner's Name: Phone #: r c,e ,' Boiler <= 100,000 Btu Contractor: ��r }/ License #: ✓ alnl- MECHANICAL Contact: Phone: Cupertino Business License#: 08. goy. lgOSr Fax: --� --- Building Permit Info: Bldg ❑ Elect Plumb ❑ Mech ❑ Job Description- / � 2" &6?6 Residential 1 Commercial ❑ Sq.Ft. Floor Area: v y q.Ft.: Cost of Proiect: s t7o Occupancy Grroun: Type of Construction:pp e�2C%f �'� Please check this box if the project is a ❑ 6 Gil FZOX second -story addition: ro'ect Size: Standard Large ❑ Major ❑ BCONSTA)MQ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler > 100K to 500K Btu MECHANICAL BBOII;ER3. Boiler> 500K to 1M Btu MECHANICAL BBOILER4 Boiler> IM to 1,75 M Btu MECHANICAL BB0ILER5 Boiler> 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Comm/Quasi BUILDING BCONSTA)MQ 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 3 zz� 1 of 3 WcCITY OF CUPERTINO CUPEkTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BMISCELL Miscellaneous Fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BNUCOM vM New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BOVERTRv1E Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum . PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE PbIg 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 PLUII11BING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING 13REMACOVER 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 BREMI RN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace > I 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 BREMFOWER 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 2of3 CITY OF CUPERTINO PERMIT APPLICATION FORM Ouantity Fee ID Fee Description Fee Group BREMSIGNAD Rnidl 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 S eci5c Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special bispection BUILDING BSVdIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary BldgPermit BUILDING BTEMPSVCS I 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 Planning Long Range Residential PLANNING ZADDCHG Address Chane BUII.DING t 3of3