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04080082One, LOr as Zq Z�W ad JyU ;LLT OS bac ep�sero f?a C4 on i�� 0 z 2 a> GC D2 UC OF FG O U�2 Fj1 CITY OF CUPERTINO 4C0N1RACTOR INFORMATION BUILDING DIVISION PERMIT BUILDING ADDRESS: PERMIT NO. 04080082 OWNER'S NAME: PERMIT LSUE DATE ON[: SANITARY 0. O OL NO, ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH (� LICENSED CONTRACTORS DECLARATION Job Description NNALM door, I hereby affirm Nat I am tic d caroler, provisions of Chapter 9 (rnmmcncing With Scmion?OOtB of Division J of the Business and Professions Code, and my license is uc��Im cl,tnd ermn� 8 7 - BATHROOM REMODEL u, a —k Dam R'(r ow camrsmf CONTRACTOR: BMS CONSTRUCTION AUG 18 1001 ARCHITECTS DECLARA ION UX 1 send rsund my plans hall W used u puM1li<rtcmds �UIL®� Licenseal OWNER -BUILDER DECLARATION NG I hereby affirm that 1 License law for the exempt from the Conine Professions Cod,: Any City m county maso L Business and Cents: following mason, 703 improve. pini.. t enstr alms ire pin sx, Which .,of. a a permit to,nns repair any swment h Permit t file also requires the applicant for such permit to files signed statement the prior ser its ceased Sq. Ft. Floor Area Valuat p LicenseLaw ( 9 - 000 theeged essand Civic) of cingWitPursuanttothepmvisionsofBoC theBusiness (Commencing Section7")th Divisiafr (co es the on, Anynneddon RUL M1e is eacmpt thcrtfrom and dm buts for Ne alleged eumplion. Any violation of exempt APN Number Occupancy Type Section 7031.5 by any applicant for a)coon subjccu the applicant to a civil penalty of not more than five hundred dollars (S500). 36924021.00 r 0 1, as owner of the property, or my employees wild wag=e as thdr amc Compensation. Required Inspections Will do the work. end the swnum is n Sluder ind oro(Icred for sale (sec. ]DIA, Business and Professions CCdc: The Conuactoes License law dues not apply to an owner of property who builds or improves thereon. and who doessuch work himself Cr Borough his Own employees, provided that such improvements are not intended oroeered for cut. If, however, the building or improvement is sold within one year of oompletiun. the owner builder will has de burden of proving Nat he did oat Wild or improve foe putyoac of sale.). 0 I, as Owner of tW property. am exclusively contracting wish licensed contractors to Co.,., Rhe project (Sec. 7004, Business and Professions Code:) The CCnuacwrs Li tuc law dote not apply W an owner of propeny who Wilds or improves thereon, and who contmcu for such projects with a eonuanor(s) licensed pursuant to she Co ddracto's Licetae law. 0 1 am exempt under Sec. , B & P C for Nis mason Owner Dau WORKER'S COMPENSATION DECLARATION 1 hereby alarm under penalty of perjury one of the following declarations: 1 have and will Tommain a Certificate of Consent to self noure for Worker's ComMo. smion, as provided for by Seniun 370() of Ne labor Code, for the pedonnarec of the work for which this permit is issued. 1 have and will maintain Worker's Compensation Insurance, as required by Section )JDD of the Labor Code. for Ne performance of the work for which this puemit is issued. My Worker's Compensation Insurance Cartier and Policy number art: Cartier. Policy No.: _ CERTIFICATE OF EXEMPTION FROM WORKERS' , COMPENSATION INSURANCE (ITu section need not W complced Side permit is far one hundtcd dollars (SIM) less) 1 certify that in the performance of the work for which thin permit is issued. 1 shall not employ any person in any manner so as to Weome stbjeet to the WorkersCompensation Laws of Caliromia. Date Applicant NOTICE TO APPLICANT: If, after making Nis Certificate of Exemption, you should become subject to the Workers Compcmation provisions of the labor Code, you must forthwith comply with such provisions or this permit shall In deemed revoked. CONSTRUCTION LENDING AGENCY 1 hereby that there is c 3 lending agency for N, performance of Whaffnm ' the work for which this p,tmit is issued (Sec. J09y. Civ. C.) s d (Sce. Lender's Name Lent Addrus j I certify thu 1 have read shit application and suu lou the above information is ' Correa 1 agree to comply wit all city and county on it xs and suu laws relating to building Construction. and hereby sathorne representatives; of this city to enter upon de ahove.mentioned property for inspection purposes. (We) agree to save, indemnity and keep harmless tW City of Cupertino against liabilitfca. judgmenu.cosu and aperues which may in any way aceto against sold City in consequence of the granting of this Permit. ' APPLICANr UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date SOU EREGULATIONS. Re -roofs Type of Roof Q / o`/ v Signature car Ppbca Date HAZARDOUS MATERIALS DISCLOSURE HAZARDOUS Will the applicant or future building occupant star, or handle hxvsmum material as defined by the Cupertino Municipal Code. Chapter 9. 12. and the Health and Safety Code, Sec don 25312(a)? All roofs shall be inspected prior to any roofing material being ❑Yes ON. If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future building occupant use equipment or devices which Fruit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? 0Yes 0 N I have mid! the hararmms materials requirements under Chapter 6.95 of de, Cali for nice Hcslth&Safety Cudc,Satirms ]5505.2553] am1255N.l umkrsvw dot ifde Wilding docs not cunendy haw a tenant. that it u MY rCSFOOM hility In Modify the axuPant of the requirtme wnMon.mepnMtdddoen„prac,ruffC.dC(OCCd my. Signature Of Applicant Date All roof coverings to be Class "B" or better tgeate d ant Dat, is s 'S CITY OF UPEkTINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Building Department, ,7 JOB ADDRESS: PERMIT # o OWNER'S NAME: L� ti 6 C . ((�D ,J PHONE # y Z 5 GENERAL CONTRACTOR: /3nS C o,p S T'. FAX # I am not using any subcontractors: /!� O! O -l?" �c/ Sigrjx6e Date Please check applicable subcontractors and complete the following information er/ Contractor Signature g--/,/-- Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical 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 er/ Contractor Signature g--/,/-- Date r L �Q. CITY OF CUPERTINO CITY OF CUPERTINO PERMIT APPLICATION FORM J u 4 (fC� U Cts N#� 6 Q Z C d 2 Date: Building Address: Mailing Address (if/different from building address): 883 F, J f -e 5- S4o 12-18 6� rVt .el 'be 1-rac Owner's Name: Phone #: lam) Contractor:9 /,�,1 ��5� �� Gr S�J2� 1 License #: 81778? Contact: Phone: Cyon63d)) say Sb 8 a Cupertino Business License#: Fax: 491,1-25-09 MECHANICAL Building Permit Info: Bldg 2' Elect 211� Plumb 2-� Mech ❑ Job Description: �1 Residential I�1 Commercial ❑ Sq.Ft. Floor Area: 12-0 $/Sq.Ft.: Cost of Project: 3' ooc7. o U Occupancy Group: Type of Construction: n Please check this box if the project is a ❑ BCONSTAX second -story addition: Project Size: Standard 0- Large ❑ Major ❑ BCONSTAX Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler > 100K 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 IHotel 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 EnergyAdd Multi BUILDING BINVESTIGA Investigation fee BUILDING 1 of 3 al 332- CITY OF CUPERTINO CITY OF CUPERTINO PERMIT APPLICATION FORM 2 of 3 Quantity Fee ID Fee Description Fee Group IMP BMISCELL Miscellaneous Fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING 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 BPLANCIIK 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 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Furnace MECHANICAL BREMFURNOV Relo Fumace > I OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREVE RAP 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 I Remodel Res Appliance ELECTRICAL 2 of 3 a(m CITY OF CUPERTINO CUP TOF Yo PERMIT APPLICATION FORM QuantityFee ID Fee Description Fee Group 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 BSPECIP.L 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 W i 3 of 3