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05060180 CITY OF CUPERTINO BUILDING DIVISION PERMIT CONT GTO RINFORMATION BUILDING ADDRESS: PERMIT N"05060180 902 E E OWNER'S NAME: PERMIT LSSUE DATE RAVIV HAHOCH 2005 ONE: SANITARY NO. CONTROL NO. „fi��R1n1 Vnr,k 1n41BrL>�OG Vr� G PERMITIOARCHITECT/ENGINEER: MBMECH �Oo LICENSED CONTRACTOR'S DECLARATION IOb ,Cr pNOP O O O w G I hereby affirm the I am licensed under provisions of Chapter Y(commencing 11411,Irk -Zw wits Section 7WO)af Division 3 of the Business and Professions Cole,and my license is J Htl9 jij? in fret force and affect, POOL DEMO Lieeve Class Lie.. Dare sf' DECLARATION EL GdmCL�C�B[�D��� ARCHITECTS DECLARATION >? < I understand my plans shall he used as public records oaU Licensed Professional g 3 OWNER-BUILDER DECLARATION 91 hcnhy affirm that I am exempt Imre Ne Cim"ll 's License Law far the 00 following mason.(Scefiun 7031.5,Business and Pmfc,vions Code:Any city or county K$ which nyuirs a permit to condom,ahca improve,demolish,or repair any structure $9000 Lai P60Fto its issuance,also reading she applicant for such permit w file a signed macaroni E4c door he is licensed th eensed pursuant e provisiam mr Of the Contou 's LicaseLaw(Chapter 9 Sq.Ft.Floor Area Valuation mi (commencing with Section 7000)of Division 3 of the Business and Profossiara Code)or a.99 - that he is eumpt thanaroe and in,basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of not mom than five hundred dollars(SSW). E 0 Occupancy Type ❑I.as owner of Ne property,mmy employcu with waguss their rete compertsaJon, will do the work and theswcwm is not intended or offered for side(Sec.7014,Business Required Inspections and Professions Code:The Comractofs License Law des not apply m e an owner or q p property who Wilds or improves thereon,and who daessuch workhimselfor through his own employers.provided that such improvements ae not intended oroRered for vie,if. h..,,the building or improvement is sold whim.ore your of completion,the coma. builder will have tha Wrden of proving that he did not Wim or improve for purpose of salt.). I,as owner of Ne property,am exclusively contracting with licensed contractors to c Trema the project(Sec.7014.Business and Profmssims Cade:)TM Contcacmri Li ccstse law tlms eat apply m m ower of property who builds or impmvc Neem,and. who concocts for such projects with a eondacmr(s)licensed pursuant m the Committees Liccne Law. I ae exempt under Sec. .B&P for Nis reason Ow Dam 2j/0S 'S COMPENSATION DECLARATION 1 hereby affirm under Penalty of perjury one of Ne following decle rations: I have and will maintain a Ce l 337M of do Lat mCoca.far for Worker's cempen- walkf r pmvidhi for by Ss ism 3]00 of the IaWr Code,far Jte pcAonnance of Use work far which this Ferret is issued. ' C 1 have and will maintain Workers Compensation Insurance,as required by Section 37W of Ne labor Code,for tin Performance of the work for which this permit is issued. My Waka's Compensation Insurance carrier and Policy number are: Cvricr. Policy No.: CERTIFICATE OF EKEM MON FROM WORKERS' COMPENSATION INSURANCE (Thu section need not W completed if the parent Is forone hundred dollars(SIM) or less.) 1 cenify the in the gaff mance of the work for which this permit is issued.I shall not employ anyperson in any manncrsnap csubjeauathc Wmrkcri ComPensstion Laws of California.Date l:��. `7n Applicant NOTICE IPPLICANT:Ir,after making this Ccnibcate of Escmption,you should , become subject in the Workc s Componential provisions of the Labor Cade,you must .,z foMwith comply with such provisions or this permit shall be dcemed revoked. Z'OCONSTRUCTION LENDING AGENCY I thereby Mo.that thoiia consuuaian lerdin P Ya g agcrmy ler the perfurmance of 135 the work for which this permit is issued(Su.3097.Civ,C.) W� Q nder's Name Uss Z Lender's Addre O Q 1 certify that 1 have rad this application and slam that the above information is LL F' coma.I agree to comply with all city and county Ordinances and sure laws elating to CU Wilding cmeduction,and hereby amhade repnscntairma ofthis city to enter upon the H Gabove-mentioned property for inspection Purposes. (We)agree to now,indemnify and keep harmicss the City of Cupertino against h Iiabilitics.judgments,costs and expenses which may in any way accrue againstsaid City UZ in covryumee of the granting of this Permit. ^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE TIONS. - Re-roofs ( Sign wrc of Applicae/Contracmr Date ' HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building mcupa.umrc or handle ovations material as def recd by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety ode,Becton 35532(x)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes RN. All Will the applicant or feue building ocapamt use equipment or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove it hararem.air contaminants as damad by the Bay Area Air Quality Managcm..t all new materials for inspection. Diurict? ❑Ycs R9 Nu 1havemad Neh 7ouussmlamrialsnquimmcnuunder Chapwr6.95ofthc Califoo- nia HcalN&SaretyCade.Sectms25505,15533a 25534.1uMc dtutifthc Wilding does ret cwnnty new a tenon that it is my responsibility an ally We occupant of the requirements which must be met Fluor to issuance of a Certificate of Occupancy Signature of Applicant Date te All roof coverings to be Class "B"or better Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408) 777-3228 CITY OF Fax(408)777-3333 UPEkTINO Building De artment JOB ADDRESS: to L £ £JJ-e s DY PERMIT # c � grf�tio �P a6ol �6 OWNER'S NAME: PHONE # 4 0�- R - 0 27 O GENERAL CONTRACTOR: T, FAX # I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: 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 ner/Contractor Signature Date CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM Ue�D/IG CUPEkTINO / N #-- 301 36 2 4 0 O� Date: 61 Z �I Building Address: I Mailing AdQress (if different from building address): q o2 E Es �ate� Or. co ev t-; r,0 ( A Owner's Name: n hone #: `t - I t$q I� G.hoc 1<gJi V �lo�' - 973 - 0270 Contractor: -rQn License#: Contact: Phone: Cupertino Business License#: Fax: Building Permit Info: ) Bldg ❑ Elect ❑ Plumb ❑ Mech ❑ Job Description: _- Residential N Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: _ Cost of Project: Occupancy Group: R" I Type of Construction: Please check this box if the project is a AdikA� second-story Elroject Size: Standard zX addition: PLar e ❑ Ma'or ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERl Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> 100K to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to 1M Btu MECHANICAL BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL BBOILERS 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 Elee Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BU7ILDING 1 of CITY OF CUPERTINO CUP TYOf O PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group 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 BOVERTRAE Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pblg Fixture PLUMBING BPGAS Gas Piping S stem Fee PLUMBING BPINTERCEP Ind Waste Interceptor PLUMBING BPLANCHK Plan Cbeck 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 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 2 of 3 C !E_ CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPERTINO Quantity Fee 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 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 PLLONGRNGC Planning LR Comme/Multi-Fam PLANNING PLLONGRNGR Planning Long Range Residential PLANNING ZADDCHG Address Change BUILDING 3 of 3