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05040095 -CITY OF CUPERTINO BUILDING DIVISION PERMIT CCONTI2.ALCTOWINFORMAT30, :11: BUILDING ADDRESS: PERMIT'85040095 S PERMIT ISSUE DATE ry SANITARY 41 CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO I BLDG ELECT PLUMB MECH Z Q Q Roo LICENSED CONTRACTOR'S DECLARATION I 1 Mmhy affirm that I am licensed under provisions of Chapter 9(commencing Job Description wish Section 70(0)of Division 3 of Ne Business Professions Code,and my license is in fir Licenlfoom seClassndeffectLie.# GAS LINE (STOVE/DRYER) & EXHAUST FOR FO Dam CenrraclM 700 ARCIIITECPSDECLARATION GAS STOVE HOOD VENT. I understand my plans shell he used as public rccolds 3a, Licensed Professimot OS OWNER-BUILDER DECLARATION <q 1 hereby arfimn'hot 1 am acmpl from she Convectors License Law for the 00 following reason,(Section 7131.5,Business and Professions Code:Any city m county $ which requires a Permit to consoles,eller,borrow,demolish,m repair any structure HZaprior(Iits issuance,also requires she applicant for such permit m file a signed statement E that he is licensed pursuanttothe provisions(If the ConmctohLicense Law(Chapter 9 Sq.Fl. Floor Area Valuation rk�$ (commencing with Section 7")of Division 3 of the Business and Professions Code)or .. that he u cu mpt rhemfrom and the basis for the alleged exemption,Any violation of $1000 Section 7031.5 by any applicant for a permit mbjeco the applicant a civil Penalty of APN Number Occupancy Type not more Nan five hundred dollars IS500). ❑1,as owner of the property,or my employees with wages Is their sale compensation, will do the work,and the struetum is not intended or offered for sale(Sec.7044,Business 362260,60': OOT and Pmressiotu Code:The Connatim'.Live Law docs Dol apply m in Owner of Required Inspections property who builds orharrow.thereon,and whodeses such work himselfer through his r r l own employees,pmvided that such imprmxmcnu are not intended or offered for sale,if. I however,the building or improvement is sold within one Year of completion,the owner. s builder will have rhe burden of proving that he did not Wild or improve for purpose of axle.). p ❑1,as owner of the progeny,em exclusively contracting with licensed commmors to 1RL5 consumer the project(Sec.70FL Business and professions Code:)The Contractor's Li. causI who contracts lsw docs r such ply m an with a of pr eor(s who sed p or improvesthe Coreoq and. whence Lacts for such projecowi'h aconvaaorp)Iicense0 pursmnuothe Commeofs �•`,\` i�/� License Law. I f ❑Lem escmpt under sec. .BA:PCf this on '- — Owner Tom-----� Data Td �� W KER'S COMPENSATION DECLARATION I hembY off under Penalty of perjury one of the following duluations: 1 have and will maintain a Cenificam Of Consent to erif-insure for Worker's Compere sation,as provided for by Section 3700 of Ne[After Code,for the Performance of the work for which this permit is issued. 1 have and will maintain Worker's COMM11510011 Insurance,as acquired by Section 37M of the Labor Cole,for to,performance of the work for which this permit is issued. My Worker's Compensation Insurance carrier and Policy number am: Cartier: Policy Nm: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not he completed Blue permit Is for one hundred dollars(IIM) less.) 1 certify that in the performance of the work for which this permit Is issuod.I shell not employ any person in any manner an ss m Weome Subject to the Workeri Compensation —� Laws M California. Applicant_� NOTICE TO APPLICANT:IL Ica making this Ccniljcate of Foreordain.p' .you should became suhjecr'o the Worker's ompensarion provisions of One Labor Code,ynm mum .Jz forthwith comply with such provisions or this permit shall W deemed revoked. Z'O CONSTRUCTION LENDING AGENCY [-, Ihereby affirm that Nem is a construction lending agency for the Performance of �i Ne work For which this permit is issued(Sec.3097,Ci,C.) 1 Q Lender's Name z Lender's Address U C) I certify that I have read This application and sow Thu the above information is ILP coarcn,l agrch to comply with all city amilcoumy Ominances and sum bas relating to 0U Wilding consuuction,and hereby smhorlx representatives of this city to enter upon the {S7 above-mentioned property for inspection purposes, (We)agree lin save,indemnify and keep handless the Ci iy of Cupertino against lar, liabilities,judgments.costs and expenses which may in any why accmc against said City 1) U inconsequence of the granting of this permit, APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale SOURCF�REG4[:A sT[gJJ 1 1 l,ls�' O 111 - t j Re-roofs _^ Signawre of ApplicanUConmctnr Dem - HAZARDOUSMATERIALSDISCLOSURE Type of Roof Will the applicaa'air future Wilding occupant voro or handle havardous ra.en.1 as defined byde Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code.stttinn 25532(.)'! All roofs shall be inspected prior to any roofing material being installed. ❑Yes Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,]agree to remove it hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. isvl.R \ MYcs XNO I have mail the hanmlws materials"t iromenu under Chapmr6.95 or the Califon Dia Hcal ASafetyCoie,Seeuou 25505,25533 and25534.I understand mu ifine building does nor tun rely have a IemnL mal 11 is my mspansorday m notily the occupant of the requirerequirenjEnt, hmosr W+na(pnormiuuance nfa Crmfcam.f cupamey. J °I y`y 61� Signature of Applicant Date 1T All roof coverings to be Class "B" or better Owner or authorized agent Dine SMA CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPEkTINO APN# / ` / Date: Building Address: —45-b 3 U yl fu- Mailing Address (if different from building address): C L c 13�O 1 Owner's Name: Phon #: �� INIV��ft NULL-AMuTU J{o6 .2--1, Contractor: License #: Contact: S� iNwAs' Phone: AoB`F--lI9dz-S Cupertino Business License#: WAyc,#I "`� ll Fax: Si 0 Z 2�;V Building Permit Info: Bldg ❑ Elect Plumb 10 Mech Job Description: GIGS 4,—e, $e�V K46ve_ ig� �� o� l/c k7z &1— Residential F�ahUkAA- Lwtr, y4ove Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: Occupancy Group: Type of Construction: Please check this box if the project is a second-story addition: ❑ Project Size: Standard ❑ Laze ❑ Major ❑ 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> 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 Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING 1 of 7�3 GQ CITY OF CUPERTINO CITY O PERMIT APPLICATION FORM CUPEkTINO 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 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 Aft BPTRAP Kitchen Trap PLUMBING of 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 Mise 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 2of3 CITY OF CUPERTINO CITY 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 Ran a Residential PLANNING ZADDCHG Address Change BUILDING 3 of 3