04020091 CITY OF CUPERT NO
BUILDING DIVISION PERIVI ,CONTRAG-TORAVFON.
BUILDING ADDRESS: W & F CONSTRUCTION lw PERMIT N%4020091
PERMIT ISSUE DATE
OW NE0.'S NAME:
SANITARY 2 COMROL NO,
NE:
BUILDING PERMIT INFO
ARCHr1ECTIENGINEER: BLDG ELECT PLUMB MECH
0 0 0 0
jo LICENSED CONRtACfORSDECLARATION Job Description
C 1 hSrtbY firm Uat 1 am li¢vcd uMcr pmvis;°�u of CMpmr Y(commenting
U with Seetido_)Oy0)°f Divia on 3nf Ne Basins�T,yry Profcssioru C°de,eM mylicenx is
�Z i�n re°�u yraCce7aWg erze-. Lle�I — � y 7Z UPGRADE HALL & MS . BATHROOMS
£F ZO Oso
oXI.'S/ C.Oha or TION~
y< I uMcrnand my Phan shill he asci axis .ceon
yU
Ct; Licensed Professional
5 OWNER-BUILDER DECLARATION
I hcmby affirm that I am caempt from dm Conuanor's License Law for the
p yO• Mlnwing essom(Section 7031.5,Business and Pr°fessions Code:My city or county -
q 4. which reqres uia permit m cMnmct..her.imp..dm
eolish.a.*1rer any nrctum
onoo
im pdormits issuance.Alan mquiresNeappliantfor Such Permit tofile Atu,cdstammcnt FLFI(iorArea Valuation
< thelheulicenscdpennant tothe ProvisionsofdmContiacser'sLicense U-(Chapmr9 Sq.
�$ (Commencing with section 70)0).1 Division 3 Of the B Mmusis sed Pwressions Code)or
that he Is exempt d¢efrom and the basis for Ne alleged erempdon.Any violation of
section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of 3 14I031;ro 0 Occupancy Type
not mart thw Om hundred dollars($500).
[I 1,as owner of thin property,or my employees with wags as theb able e°mpeaudon,
wan da the work.ane Neawcwet:net mmndcemoncred mrsale(Scc.70W,Benrmu Required Inspections
and Pmfccdou Code:The Cono erne,l.keme law does not apply in an owner of
propetywM buildsoimproves thueon.and whodoes¢ah workhimself orlMughhls `
own employes.provided Natauch improvements are not intended moBere i(risk.if.
however.Ne building or improvement Is sold within one Year of ComPleorm.the owner.
Witter will have the burden of proving Nat he did not build or improve for pure.¢of ����e
sans). � �
I,as saner of the property am exclusively Contiu.4ng with licensed cummucmn to
..La d project(Sec.7614,Business am Prolosedproperty
who u Code:)The Conuaecon.and
nese law dos noupply m an owner.of=.,(,who builds or improves Neuron,and
who contracts such Drojccts wiNamnnacmr(s)Ilatucd pulawm mlhe ConlnnaYa r�� � n
1�+ce-e Law. 2004
❑ l unexemptundersec. ,Bk PCfor Nsr-awn ■
Owner Data R 11I■ ®I r p �awaffiraffirmORKERSCOMPENSATIONDECLARATON U ■■r.r 'w\V•■�/!�
1 hereby eunder penalty of perjuryro oor the following decimations'
have and will maintain•CaNOole of Come-In self-m-ure for Weram"Comper-
mn,ss provided for by section 37M Of the labor Code,for the admtca omof the
work for which this permit is issued
❑1 Nm aM will maintain Worse,Compcnvdon Insurance,as required by section .
37M of the labor Code.for the Performance of the work for which this Permit is issued.
My Worker's Compensation Insure"¢carrier and Policy number art: s
—i prI la Fvr?o ry No.: j 1 7 V
CERTIFICATE OF—FXEM�N MOM WORKERS'
COMPENSATION INSURANCE
Crltls section need not hccomplcwd If the Nrleitisforonehundrtd dollars($100)
or leu.)
1 unify Nat ia rmance M the work for which this Permit u issued.i shill nut
emplcyanyper�e e' lny manner in a in become subject 10 th°Worked Compensation
Iawsof C.lifo am
Appliruu
bj APPLICANT:If.Co making Nu Ccsiins O the
Labor o0,you should
bjen m the Worker's Compensation Provisions Of Ne labs Code,. mus
'Z roMwi comply with such previsions or Nis Permit shall he decreed evoked.
�C)
7 y tha
CONSTRUCTION LENDING AGENCY
1 hereby affirm t there is o Coro im.lending-i for the performance of
L? the work for which Nis permit is wised(sec.3097,Civ.C.)
G 0lander',Name
L Lender's Addeo
D 2
Q 1 certify Nn 1 have mad this application and sum Nat the above infmmniot is
L(—'
correct.I agree to comply wit ill city am county ordinances am sum laws relating to
v W1din(We) ucd n.toand m,indbyamy andIrtpesturoul sseor Ci;s city mcnmrupon Ne
y ahom-mentioad property for inspection purposes.
w 0. (We)egrce to five,indemnify and kttp harmless the City of Cupertino against
to liabilities.judiments.costs and exposures which may in any way accme against said City
)z in eonxequena of she granting of this perobb. Da
.r APPLICANT UNDERS"fANDS AND WILL COMPLY WITH All.NON-POINT Issued by:
SOURCE RF 7N5�—•
a l rr Re-roofs
nw ravhaHAZA Curr - °im Type of Roof
HAZARDOUS MATERIALS DISCLOSUR
Will the et orforms building Occupant me o haMlc alloamamriil
ss de, by the Cupertino Municipal Co@Chapter 9.11.and the Health and Safetycok.Sccmbn
zs532(.)7All roofs shall be inspected prior to any roofing material being installed.
El Yes °
Will the applicant or future building Occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
bavardous air conumimgfs as QcOncd by d¢Bay Ara Air Quality Managem°nt all new materials for inspection.
p Yca
I have rad the hasardou,materials requimments under Chapter 6.95 of Nc CIliforr
nu HcalNh Sa,cty CMM sadom13505.15533 arW1553a.l undcrstud thui(tM Wilthng
docs not currcmly h° a one-,Nat it rs my ms mibility m notify the..Pso fir Nc
rege;remntswNcn ,Ib mmpribrwiesencebraCetieammrkapm � gignatureofApplican[ Date
m. on agent
DowAll roof coverings to be Class"B"or better
• M" I v ,I O v c3 m o j a n� rT
at
OWN=� V � . i o~ ryC�
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OR I'
VITY OF CUPERTINO
CUPEYOF PERMIT APPLICATION FORM
q1KPN # 011
Date: Z
Building Address: Mailing Address (if/different from building address):
21 -75 ills or:T
Owner's Name: Phone #-
S hF� Koo 650) g07 '7
Con� Ito n n1License #: 7 �V Ot_ z
(_,pS-TIZVCTi O��
Contact Phone: sz; —7493 Cupertino Business License#:
��� CC.lemA.t Fax:
Buildink Permit Info:
n
Blddog Elect Plumb Mech
Job Description:
Residential ❑ o r
Sq.Ft. Floor Area: $/Sq. t.:
Cost of Project: A7 Occupancy Group:
SC�CY�
Type of Construction: Please check this box if the project is a
second-story addition: ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER OtherAppliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to IM 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 <_ IOOOA ELECTRICAL
BELEC1001 Elec 600V > IOOOA 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
1 of
E: A ATY OF CUPERTINO 0
CUPEYOF PERMIT APPLICATION FORM
7 Quantity Fee ID Fee Description Fee Group
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BOVERTBIE Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE PbIg Fixture PLUMBING
BPGAS Gas Piping System Fee PLUMBING
BPINTERCEP Ind Waste Interce for PLUMBING
BPLANCHK Plan Check Fee. BUILDING
BPLANCKADD Plan Check Add Multi BUILDING
BPLANCKREP Plan Check Repeat Fee BUILDING
All BPREPIPE Re i e Of Fixtures PLUMBING
BPSEWAGE Sewa a Disposal PLUMBING
BPSEWER Sewers PLUMBING
BPSPRINK Lawn S rinklerBackflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVEN'T Alt of Drain &Vent PLUMBING
BPWATER Instalt/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
BREngURN 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 A liance ELECTRICAL
BREN20LE Pole/Platform Fixture ELECTRICAL
BREMPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Re air/Alter Heatin MECHANICAL
BREMRESAPP Remodel Res A liance ELECTRICAL
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Si s, Mar uee I ELECTRICAL
2 of 3
PITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPERTINO
Quantity Fee ID Fee DescriptionMFee Grou •
BREMTHEATR Theatrical Lighting TRICAL
BREMVENFAN Vent Fan Sin le DuANICAL
BREMVENSYS Ventilation S stemANICAL
BSCBLVD Scb S ecific PlanLDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res •BUILDING'
BSPECIAL Special Insection BUILDING
BSWEN4 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
CITY OF CUPERTINOa:4�rx ^`
BUILDING DIVISION PERMIT 2kCONTRACTOR NFORMATION.y
BUILD�NcypDpgrs S Pa"W & F CONSTRUCTION "%4020091
75 DR
ERfSSiNNAMMEE: PERMIT ISSUE DATE
==7m XAn 111,1200A
ONE: SANITARY NO. CONTROL NO.
ARCHITECT(ENGINEER: BUILDING PERMIT INFO
BLDG ELELT PLUMB MECH
u00 LICENSED CONTRACTOR'S DECLARATION Job Description
(� I by mm that I am Ihmmcd under povisions of Chapmr 9 fmmmcreing
with Seen ] )af Division3ofthc Busine Pro(cuiam Code,andmy ma..'s
in TO�t�ome effect —n X 9 7Z
op"SO —L . UPGRADE HALL & MS . BATHROOMS
n F Canor Y ry17aaC
qq ARCHPIECTSD TION
1 undcra and my plans shall W used aspW is retards
�yU
3 LLa n l.icemetl Profesuanal
3 OWN r..exempt f DECLARATION
I heoby.(Sere Nat Jr..exempt fon use Ganitaclmf License law for the
00 following moon.Permit
i 70313.Badness and Proans.deriull Calc: Pa city s courtly
s�$ which rots har a Pemst ne cmeatrthe altar,improve,h Per i h,or repair any structure Ono
prior it)its issuance,alsore to the the applicant for such permit mi.a Law naomem
S�S�< Nn he is licensed pursuant to the provisions of the Confiscates License law(ChaPor9 Sq. Ft. Floor Area Valuation
d�o (mmmeneing with Section 7000)of Division 3 of the Business and Prefcssinm Cnde)or
that lic is boxis
the glcgcd
of
section]03exempt bya"applicafirain nt floor a pertNts subjects Ne applicantexemption.
po a civilpenallyof
not more than five hundred dollars($500). 3��ro O Occupancy Type
0 1,u awms of tha pmprny,m mY employm with cages ss Usev sole mmpensatim,
willda thework.anamesuunam i nolimmridedmoQered misale(See.7044,Business Required Inspections
and Pronse Professions Cade:The Comsacturs LiceLaw docs not apply to an owner of q P
property who Wildaorimprovesthereon.anti whodoessuchworkhim e f orthough his
awn employees.provided thatsmh improvements sm not intended oroResed forsale.If.
however.the building or improvement is sold within rpm year of mmpletian,Ne owner
Wilder will have the burden of Lanvin,thin he did nm Wild or improve far purpose of j
sale.).
❑h u awrter of the property,am exclusively eonuuOinL with licensed commemm to
construct the project(Sec.7044.Business and Professions Code)The Cmtiactors U-
mnu taw does out apply m an owner of pmpcny he Wilds or improves thereon,and.
who Contracts fm such pmjeets with a conuactor(s)licensed pursuant to the Coneraeota
scar law.
am exempt under See .B&P C for this mason
er Dam
WORKER'S COMPENSATION DECLARATION _
1 hereby afEnm Kindly nally of perjury one of the fallowing declarations:
I haw and will maintain a Cerue
fca of Consent to self-insure for Walkerm
Walkers Campc
sation,as provided for by Section 37M of Ne Labor Cade,for the performance of the
work for which this permit is issued.
❑1 haw and will maintain Work,'.Compcmation Imuranca.M acquired by Section
37W of the tabor Codc.for on,performance of the work for which this permit is issued.
My Workers Cmmpenandon Insumnw carrier and Policy number art:
C 'er. o: 11-7 4,
� .l F fORKERS
COMPENSATION INSURANCE
(Thisectim need not boeompleted if the Permit isforone hundred doll=($]W)
less.)
1 anify That c pe ormemc of sec work for which this Permit u issued.)shall not
employanype y manor so ss o become subject to the Workers'Compensation
taws of Cattle am
Applicant
TO APPLICANT:If,after making this Cenincao of EacmPtian,you should
bjcet or tW Worker's Compensation povislons of Nc labor Code you am
Z forthwi comply with such provisions an this permtuhall bo deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
(r .4. I hereby alarm Nat them is a cmutmcem lendingageney far the perfornaoceof '
[� r7 1W work far which Nis permit i issued(See.3M,Co.C.)
W Lender's Name
G Lenders Address
V O 1 certify this 1 have rod this appliotion and slate than the above infoormatim is
W F coma 1 agree to comply with all city and county ardinames and sum laws mining to
OU building construction,and hereby aulhorio opresemelivv of this city to enter upon the
} W above-mentioned property for inspection purposes.
(We)agree to save,indcmmify and keep hannlecs the City of Cupertino against
Cn liabilities judgments,costs and expenca which may In any way accrue against said City
U Z in consax,m ce of the granting of this Permit.
r APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Da
SOURCE RE
Z jar ° Re-roofs
u f licam/Comraclm Dam
HAZARDOUS MATERIALS DISCLOSUR Type of Roof
will thc applicam or furore building mCap antamCar handl.Wra n aus..Wrist
Sncd by the Cupertino Municipal Cud..ChaPur 9.12.and @c Health and Safety
.Sentm 25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will sec aPplkam or future tool occupant IW equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it haradnm air mnumIna an coned by the Bay Area Air Quality Management all new materials for inspection.
DisuiaT
Yes An
1 have rod the bxnrdots mamriats ox,ro.roma under Chapter 6,95 of the Califon
.is Health&SafctyCode.Scetions 25505.]5533 road 25534.1 understand thn if do Wilding
does not .ntiy he a¢not that it is my respomihility o notify the mcupan of Nc
mquiemenawhich R W mel polar to issuance of a C.NOeae of Occupan �y/� Signature of Applicant Date
ora ori. agent Dam All roof coverings to be Class"B"or better