03090079 CITY OF CUPERTINOrv:+pax
BUILDING DIVISION PERMIT -CONTRACtrt�R INFOILMATIO�'
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BUILDING ADDRESS: PERMIT NO.,3 0 9 0 0 7 9
10450 C-TRD337IRW PIT
OWNER'S NAME: PERMFF MUUE DATE
10 NE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+Op LICENSED CONTRACTOR'S DECLARATION' Job DDSCTipllOn
WC 1 hereby affirm that 1 am licensed under provisions or Chapo:r Y(commencing
U with Section70(y)of Division 3 or NC Business and Professions Code,and my license is
mrwlmReanaerrect. REMODEL 2 BATHROOMS
..on
4= License Class Lic.S
�y ct Dam.Contractor
1 ARCHITECTS DECLARATION �i
L� 1 understand my plans shall the,used as public records .001
i/
eta. Licensed Pmfcaaffir yp
1�-.' OWNER.exempt Non Me RATION C
2<E I hereby reason.(Slim that 11. cBcmpl from the Cssors on e:Any Ccense Law far the /
0 o following.I.. (Section 1(131.5,Business and Professions Conde:Any city or county 0
$� which requires a permit to cnniWCL alcor.Improve,demolish,or repair any structure
iy prioni its issuanre,alsumgwms the apPlicam lnrsueh permiun RleasigneJ xlamment
<
that he is licensed pursuant In(be pmvisicruof the Contractor's License law(Chapter y Sq.Fl. Floor Area aluation
e�ct (commencing with Section 7")of Division 3 ofthe Business and Professions Csxk)ur
$ Nat he is exempt ucmfrom and the basis for the alleged exemption.Any violation of 36911017 . 00
Section 9031.5 by anyapplicant for apermit subjects the applicant to a civil Penalty or APN Number Occupancy Type _ .
not marc Nan Gvc hundred dollars(S500).
I,as owner or Ne propeny,.rmycmployces with wages as their solecampensalion,
will do Me work.and lhcstmnae is not intended oroRered for sale(See.7044,Business — d inspections
and Pmfecsions Code:The Contractor's License Law does not apply t.an owner of P
property who builds.,impfmss Me.W.lod wh.d.swch work himself.,through his 102 - PIERS
own employers,provided that such improvements are not intended or offered tarsale If. 103 — UFER
however,Ne building of improvement is sold within^rte year ore..o.ti.a.the owncr-
builder will have the burden of proving Nal he did not build or improve for purpose of 104 - REBAR
a)e)' 105 - ANCHOR BOLTS
I,as owner of Ne property,am exclusively contracting with licensed contractors I. -'
struct the pmjcn(See.7064.Business and Professions Code:)The Contractor's U. 106 — SEWER & WATER
Cense law Coca not apply m an owner of property who builds or improves daemon.and 202 - UNDERFLOOR PLUMBING
who contracts for such projects with a contractor(s)licensed pursuant m the Contractor's
.LicenaeLa, 203 — UNDERFLOOR MECHANICAL
❑ Iarm exempt anerSec. B&Pe m�iyo�u2stn 204 - UNDERFLOOR FRAME
D" �`" - 205 - UNDERFLOOR INSULATION
WORKER'S COMPENSATION D CLARATION
Ihembyarmanunaerpen.nynrI jury an mnawingdeelaratmns: 301 - ROUGH PLUMBING .
have and will maintain acenificomofConsent mxlf-insurafor workersenmpen. 302 - TUB & OR SHOWER
Wim,as provided for by Section 3700 of the labor Code,for the perfo,m.ncc of the 3 03 — ROUGH MECHANICAL
work for which this pormitiaissued. 304 — ROUGH ELECTRICAL
I]I have and will maintain Worker's Compensation Insurance,a required by Section
3900 of the labor Code.for the performance^r the work for which this Permit is issued. 305 — FRAME
My Workers Compensation lasumace Cartier and Policy num Per are: 306 — HOLDOWNS
Carse° Policy No.: 307 — INSULATION
CERTIFICATE OF EXEMPTION FROM WORK ERS'
COMPENSATION INSURANCE 308 - SHEETROCK
mdrsectionnecd lwthec.mplcledlftbe pori,is rmanchundreddollars($100) 309 — EXTERIOR LATH
or lC59.) 310 — INTERIOR LATH
I certify that in the performance of due work for which(his permit is issued.1 shall nut
employ any pennon in any manger sn ss to become subjecuo the Workcfi Compensation 311 — SCRATCH COAT
Laws or California.Dass 313 — ROOF NAIL
Applicant
NOTIC E TO APPLICANT.If.after making this Ccnilicale of Exemption,you should 501 — FINAL ELECTRICAL ENERGY
become subject to the Workers Compensation provisions of the laser CMC,you must
]Z forthwith comply with such provisions;orthis Permit sballxdeemed revoked. 502 — FINAL PLUMBING ENERGY
zo CONSTRUCTION LENDING AGENCY 503 — FINAL MECHANICAL ENERGY
I hereby affirm Nal More is a construction lending agency for the perfurmanm of 504 — FINAL BUILDING ENERGY
Y,> the work fur which this permitisissued(Scc.3(197,Cry,C.) 505 — FINAL ELECTRICAL
+1 Lender's Name
D Z L naersAedma 506 — GAS TEST
1 certify that 1 have read this application and sure that the Mose information is 507 — FINAL PLUMBING
(•" correct.I agree to comply with all city and county onlinances and sum laws relating t.
J C.7 building construction,and hereby autharim representative or this city to enter upon Ne W5C
AL
U above-mentioned property for inspeNon purposes.
r LL (We)agree to save,indemnify and keep harmless the City or Cupertino against
fg linobilom,ridgmenu,cosuand expenses which may inany way accrue againsteodCity
j in consequence or(he granting of this permit Date � b
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL ON P INT Issued by: ORKS
UR RE LAT 5. /� d
Re-roofs
Signature of AppliaDa
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the a Curg rt or future building occupant store or hanand the
h Health
a Material
u def rtes by the Cupertino Municipal Cuda Chapter 9.13,and the licehh and Safety
Code.Scainnu53z(an , ll All roofs shall be inspected prior to any roofing material being installed.
❑Yrs C Nn
Will the applicant or future building amnpaatuse egmpmeata,deviceswhicM1 If a roof is installed without first obtaining an inspection, I agree to remove
(it hanrdnas of, cogamimnts as defined by Ne Bay Arca Air Quality Management all new materials for inspection.
istricO a� /
t]Yes
1 have read the bvaN.us..,lots ex aimmcnts un(lor Chaper 6.95.rtbe Carlo,-
' ria Health dr SarclyCode.Seetium 25505,35533 and 25534.1 undcrsuM Mairw holding
does not amently have a Count.that it Is my respansibiliiy In oil ry the oce not f the
requirements whi h I mclatortuistandce Dfa CcrufMorocco xSignature of Applicant Date
-— All roof coverings to be Class "B"or better
O c,.,au(horincJ agent � O D D
Q- C*Y OF CUPERTINO q
CITY OF PERMIT APPLICATION FORM 0 _7?
CUPEkTINO
N # Date:
Building Address:
/64,5-o
Owner's Name: Phone #: S '7q 7
G(' c�. i 23 Z/0? -c95
Contractor: ` �S r ' l I� nut l '�I=�C, License#:
Contact: F b Gl Cupertino Business License#:
Chc\,5
B 'YdingPerin� fio:
Elect Plu Bldg b M
escription:
Residential ❑ C ercial
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: Occupancy Group:
Type of Construction:
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILER1 Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1 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 Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
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COY OF CUPERTINO �
CITY OF PERMIT APPLICATION FORM
CUPEkTINO
Quantity Fee ID Fee Description Fee Group
BMITIGATR Res. Housing Mit Fee BUILDING
BMNEWMULTI 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
BNUNIULTI 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 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
BRENLUUTAN 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
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CITY OF �
CITY OF PERMIT APPLICATION FORM
CUPEkTINO
uanti Fee 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 Sips 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 Swinuning 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 PI umbing Permit Issuance PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
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CPPV OF CUPERTINO
BUILDING DIVISION PERMIT �CONTRAC RINFORMATION
. $v ..:turd"? .a,,: aix. ...I..$•'6::'.���.
BUILDING ADDRESS: ""`b3
ERMITN .3 0 9 0 0 7.9
OWNER'S NAME: PERMIT ISSUE DATE
E: SANITARY NO. CONTROL NO.
ARCHITEC tENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MSCI)
IOo LICENSED CONTRACTOR'S DECLARATION Job Description
C Z F 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing p
e<ca
With
Section 7M))of Division 3 of NC Business and Professions Code.and my license is ww..
mmurorceAndeffect. REMODEL 2 BATHROOMS 11YALED
j t2 i License Clam Lie.N
4;0 Date Commerce at
ARCHITECTS DECLARATION ��� 2 ZOO4
f n I understand my plans shall be used as public records
c a.t; Licensed Professional R
s3 OWNER-BUILDER DECLARATION BUILDING
f I hereby alarm that 1 am exempt from Nc Convenor's License Law for the
O o following mason.(Section IID I.5.Business and Professions Code:Any city or county
Q which reports a permit 10 smarract.aper,improve.demolish,or repair any structure
prior Rs its issuance.alsomquires the applicant Infidels permit to file a signcdnamm<m
< that he isbeersedpursuant tothe provisionsofdue Contractor'aLicense LAW(Chapter9 Sq. Ft. Floor Area Valuation
.Rn (commencing with Section 7000)of Division 3 of the Businoss and Professions Code)or
$
that he is exempt therefrom and the basis for the alleged exemption.Any violation of 36911017 . 00
Sernon7031.5byany applicant for apem,itsubjects the appheanttoacivil Penapyof ' APN Number Occupancy Type
not mor than five hundred dollars(5500). - - -—-
0 h as owner of Iw propene,m my employees with wages ss their ooh compensation, FOUND
will do the week.and he structure is not intended or offered for sale(Sec.7INW.Business _
and Professions Cede:The Conunnoh Licence law docs not apply to an owner of d Inspections
properly who builds or improves thereon,and whodoessuch work himedfmr through his 102 - PIERS
Own employees.provided that such improvements are not imcnded or offered for sure.If. 103 - UFER
however,me building or improvement is sold within one year of completion,the nwner-
builder will have me burden of Proving that he did not wild or improve for pdmore of 10 4 - REBAR
sale.). 105 — ANCHOR BOLTS
I.as mvrrer of Ne property,am exclusively contracting with licensed contraction to
street the parolee,(See 7(uW.Business and Professions Code:)The Cormanm's Li- 106 - SEWER & WATER
ecto c Law does nm apply to an owner r,,.,,y who wilds or impmacesheroom,and 202 - UNDERFLOOR PLUMBING
who contracts for such projects with a contractor(s)licensed pursuant m the Contractor's
Cieenr L.w. 203 — UNDERFLOOR MECHANICAL
O l tun exempt and r Sec. .B&PC rIld masmi 204 — UNDERFLOOR FRAME
ac Date f0 205 - UNDERFLOOR INSULATION '
WORKER'S COMPENSATION D CLA RATION
I hereby affirm under penauy of perjury on folr wing d«lariumms: 3 01 - ROUGH PLUMBING
an and will maintain a Certificate ofConscm to self-iname(OrWinkerSCroarparn' 302 — TUB & OR SHOWER
on,u provided for by Section 3700 of me Labor Code,for me performance of the 303 - ROUGH MECHANICAL
work for which this Permit isismed. 304 - ROUGH ELECTRICAL
0 1 hale and will maintain Worker's Compensation Insurance,As required by Section
37W of the Labor Come.for the wilficrinance of one Work(of which this Permit is issued. 305 - FRAME
My Workers Com pensation Insurance carrier and Policy number art: 306 - HOLDOWNS
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORK ERS' 307 - INSULATION
COMPENSATION INSURANCE 308 — SHEETROCK
(Thissection aced not becompletedif the Permit is for one hundred dollars($101 309 — EXTERIOR LATH
' nr IC55.)
1 ecrify 0.11.the perfnrmancc of the work far which this Permit is issued.1 shall am 310 - INTERIOR LATH
employ any Person in any manner so ra in become subject to the Workers'Compensation *311 - SCRATCH COAT
Laws of California.Da¢ 313 — ROOF NAIL
Applicant
NOTICE TO APPLICANr:lf.after making this C.nificam of Exemption.you shouW 501 — FINAL ELECTRICAL ENERGY '
w<ome subject to the Worker s Compensation provisions or the Iawr Code,you most
)Z, forthwith comply With such provisions or this Permit shallbedeemed mwkw. 502 - FINAL PLUMBING ENERGY
z� CONSTRUCTION LENDING AGENCY 503 — FINAL MECHANICAL ENERGY
I hereby affirm that there is a construcinn lending agency for the Performance of 504 — FINAL BUILDING ENERGY
Z' > the work fur which his permit is armed(See NZ07,Civ.C.)
s7 A Lxnder'sName 505 - FINAL ELECTRICAL
2.Z) z L ndcrsAddm 506 — GAS TEST
I reify that 1 haw read this application soil some that the shove inAndoi l pct is 5 07 - FINAL PLUMBING
F cit.I agree to comply with all city and county ordinances and stain laws relating 1.
jU building construction,and hereby aumorim mpracomanS of his city to enter upon me FIN MEC CAL
a ahovcmentioned property for inspection purposes. 1
(We)agroe 1.save,indemnify and keep harmless Ih.City of Cupertino against 0 9 F I
r rA
liabilities.judgmins.eoxisand expenses which may inany WAY Accrue against SaidCity 5 NG
J z in
APPLICANT eof the grandog of UNDERSTANDSthis AND Permit.
WILL COMPLY WITH ALL ON-P IM Issued by:5 C WORKS Date (b
OR RE LN
S.
� /o a Re-roofs
Signawre of Applimntraemr Da
ZARDOUS MATERIALS DISCLOSURE Type of Roof
Will d¢apt or future building occupant stare or handle hazardous deamdal
az defined by the ina Municipal Code.Chapter 9.12,and the HeaWr and Safety
Cod.,Section 155All roofs shall be inspected prior to any roofing material being installed.
E]Yes �NuWin meat or umrc buildin ant use. ui ent or devices whichIf a roof is installed without first obtaining an inspection,I agree[o remove
ras oc.dp v Pm'nodous airminants as defined by me Day Arca Air Quality Management all new materials for inspection.
w/OYcs �VQ1�`I have mail zardous materials requirements under Chapter 6.95 of the Califonria Health✓E Safety .Sections 15505.25533 and 25534.1 understand Nm if the wildingones not currently mnam,that it is my respunsihility to minty the race ant f m.requirements whonmet prior id issuance of a Cembi-roof Geed y rz Signature of Applicant DateO .r tosuthodam � e All roof coverings to be Class"B"or better U