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04030196up= Op <Q� dpi nFFOWWWy �W< gLLrn J �p0 tl�N _z> ^Fa r. J CITY OF CUPERTIINO,:�,,.• CONTRA CTORFINFORMATT'ON BUILDING DIVISION PERMIT zxx, ........... .. BUILDING ADDRESS: TOM'S PLUMBING PERMIT No. 04030196 OWNER'S NAME: PERMIT ATE DATE JANET HONE: AMTARY 0 OL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 LICENSED CONTRACTOR'S DECLARATION Chapter 9 Job Description 1 busby Nal l am limned under provisions of (commencing�� g3f lis ® sn Ims® wish Sxtiw TO(q)af DivitionJofdr Badnw amid Rofrsriorts Code and mylicenxr ) of ®�O[L131f in.fullClass mre�� el' % License tc=oax Lk.g 1py19L� GAS LINE FOR FIREPLACE Dale ECor APR 0 6 2004 RCHRECTS I I understand my p=ans shall W used as pub c mcmda BUILDING BUILDING Licensed Professional DECLARATION O.1NER-BUILDERfrom I bunch, Nal 11. cxcmpe Gam the Cw CieLicense taw far ted n. oli Code: Any city or ro . (Sector TBJL9. Buaircss and AC followingPermit which ere, de or Samnmm structure priori re COus meamfur, itingany itsi.ad+,fres== the such permhu prior m its issuance. also requires the applicant far such permit m 01eo signed su¢mem that to Um Contractor Lixnsctaw(Chapter 9 Sq. Ft. Floor Area Valuatio 70M)provisionfirthe menccenwdpursuant f eBusiness Cade) or Oomm is engwiWsereioainand ml.yed cP Any IME,ofrortWeged avand.m. Any vi Oat io is exempt therefrom and Ne aper far the of Section cara to it Penalty ayracy+replicantfar apermit MbjectsIlrapplicanttoacivilpcmlryof j 321 N_gtiDtgro0 Occupancy Type dum not mom Nan Bee hundred dollus ($500). I. to owner of the Ptapmy, m my aapleytss with wages as thew sol. Compensation. will do Or, work, and 0,swctum is not Trended or offered for sok (Sec. 7W. Business and Professions Cade: TW Conuacmfs Lice. law does rot apply m an owner of Required Inspections property who builds or improves thereon; and who does such work himself ar through his awn cmplayces. provided Nal Such Improvements am nallnumeed oraRCRd for tale. If. builder Nebuildingorenofpmenag Sokediinme year of completion. purposeof builder will Wve the Wrden of proving all he did not build of improve for purpom of nit,.). 1. u was of the Prop.ny. am exclusively contracting with licensed contractors to Construct the project (Sec. triad. Business and Proposal Cade:) The Contractor's Li - cure law docs nm apply to an owner of property who Wilds or improves IWmon. and who contracts for such projects with a canuazor(s) licentud pursuant to the Comommes Licencelaw. ❑ 1 On exempt under Sec . B & P C for this reason Owner Data WORKERS COMPENSATION DECLARATION 1 thereby affirm under pealty, or perjury one of the following declarations: O 1baveandwillmaintaina Cer rtmMofCoventtomlf-insumforwarkofsCompeer saran. n provided for by Section 3700 of the labor Code. Tor the performance of the work for which this permit is issued. Svc and will maintain Workces Compensation Insurance, u required by Section T00 of the labor Code, for Oc performance of the work for which this Permit is issued. My Worker's Compcou�nion�In/aurance artier and Policy n m Wr art: Carrier. BAPM(/'� %it, No.: 141 I S 27-f CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE (Thr scctiw need not W completed Vila, permit is Intent, hundred dollars (5100) or less.) 1 eenify Nal in the Performance or the work for which this Permit r issued. I shall not employ any person in any manner so u to Wcome Mbjem to the Woractircompensalion Laws of California. Date Applicant NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should become subject to thc Worker's Compcesauan pmviston of tar Labor Coo, you must foMwith comply with such provivii. or Nis Permit Nall W deemed sevokcd. CONSTRUCTION LENDING AGENCY 1 hereby affirm Nat Vert is a construction lending agency for the performance or Oc work fur which this Permit is issued (Sec. 7097. Cie q Lender's Namc Lender's Addroz I amity Nal 1 have read Nr application and mule Net the move information is Correct I I. to comply with all city and only omimncea and state laws elating b Wilding construction, and hereby auNarim mpmMmadvea or this city in enter upon the shove -mentioned property for inspection purposes (We) agree to save, indemnify and keep harmless IM City or Cupertino against liabilities. judgmi class and expenses which may in any way Memo against Mid City in couch once of On granting of this permit APPLICANT UNDERSTANDS AND WILL COMPLY WITH A L NO -POINT Issued by: Date SOURCE REGULLA�IONS. `y M nl�oyt Gvl. 2 zti / Re -roofs Type of Roof SiVT of App eantrCantmcter Date HAZARDOUS MATERIALS DISCLOSURE Will the applicant or for= building occuWnt nom or handle M mous material is, defsted by the Cupertino Municipal Code, Chapter 9.11. and the Health and Saruy me,Section155J3(a)T All roofs shall be inspected to any roofing material being installed. cYes 9Qo prior If a roof is installed without first obtaining an inspection, I agree to remove Win the applicant or future Wilding aecupant amt, agmpmem ar devices which cmb ImMadous air contamirunts M defined by the Bay Asa Air Quality Management all new materials for inspection. Diul (]Ye An than mad lheh=dN mawdalsmquimmenuundcr Chapurh.95ofthcCalifor- niaHcmth&Smcty Ca ,. cecom35505.]5577and25574. 1 understand thtirthc building does not currently have a to im. Our it is my res nodality m notify aceupans er the mm entswnkh nW�etF. a nraCerdfiedrnf2 y Signature of Applicant Date Zaney.� Y�l�\ 1 Z All roof coverings to be Class "B" or better own 'mum , d.PCm Dam r�J CITY OF IUPER,TINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 Fax(408)777-3333 Building Department JOB ADDRESS: PERMIT # og o3-41 i-/� OWNER'S NAME: PHONE # -7 2 ' ci GENERAL CONTRACTOR: FAX # I am not using any subcontractors: 5 e( -7r z Z re SignatuDate Please check applicable subcontractors and complete the following information: Owner/ Contractor Signature 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 Owner/ Contractor Signature Date CITY OF CUPERTINO CITY OF CUPERTINO PERMIT APPLICATION FORM T Quantit Fee ID APN #Date: Zrp 3� o3S ZZ ms BAPPLOTHER Building Address: Mailing Address (if different from building address): MECHANICAL OSc( I f � o �(f n- c e z v n u Q- 8501 Bldg Permits . foot Owner's Name: Phone #: Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler > I OOK to 500K Btu Contractor: T OV. g License #: Boiler> 500K to 1M Btu Contact: Phone: q67-6d/c) Cupertino Business License#: Boiler> 1M to 1.75 M Btu Fax: q7 - 512 BBOILER5 Boiler> 1.75M Btu Building Permit Info: BCONSTAX Bldg ❑ Elect ❑ Plumb Mech ❑ BUILDING Job Description: r ✓LPOC Ace - Ind/Off/Comm/Quasi Residential EL Commercial ❑ BCONSTAXBQ Sq.Ft. Floor Area: $/Sq.Ft.: BCONSTAXH Cost of Project: a Occupancy Group: BCONSTAXR Type of Construction: Please check this box if the project is a AML Elec 600V <= 1000A second -story addition: ❑ T Quantit Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILERI Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler > I OOK to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to 1M 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 EnergyBUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING I of 3 C) CITY OF CUPERTINO CUP TYOF O PERMIT APPLICATION FORM 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 BREMAMHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Fumace 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 BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL 2 of 3 &-- CITY OF CUPERTINO 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 Change BUILDING 3 of 3 t t