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04040001 CITY OF CUPERTINO "x'"'- "�°`• � °'x ' ` ''' BUILDING DIVISION PERMIT CONTRAC�'TORINFORMATION •• BUILDING ADDRESS: PERMIT NO,o�y40 4 0 0 0 1 n77 T4yAMMTqp0RT MR OWNER'S NAME: PERMIYISUEDATE t 6d19 NE: SANITARY1,12 O AOL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 400 LICENSED CONTRACTOR'S DECLARATION Job Description in1 Mrcby affirm that I me licensed under provisions of Chapter 9(commencing P with Section 7")of Division 3 of the Business and professions Code,and my licenu is to full fora.ad offset. q= License Class Lle.g REPLACE FURACE & ADD A/C, U�uIvEWahm� / n o Dane Contracts' q ARCHITECTS DECLARATION q .t 2 1 underaund my plana shall In,used u public records APR 2 tI LO oy JyU 3uD Licensed Pmfesswnal OWNER-BUILDER DECLARATION 1 hereby affirm Nat 1 am exempt from use ComamoYs License law for the ��®�� 00 following aeon.(Secvun7031.5,R" u in .and Pmfcount msoos COde:Any city or county BUILDING tai which rep.j.a Permit to eormsucL alter,improve.demolish.or repair any Mrucou FZ< prior to its issuance.also requires da applicant forsoch Permit m rile a signed sutemem Nat he is licensed pursuant o the provisions of the COnuscusr's Liao¢Law(Chapter 9 Sq.Ft. Floor Area Valuation 'I n (Commencing with Section 7")of Division 3 of the Business and Prafc ms Code)or that he is exempt thesefom and de basis for the allgcd exemption,Any violation of Section 7031.5 by any applicant for a permit objects the applicant to a Civil penalty of 3 MIS Mt&Ibel 0 0 Occupancy Type am was than five hundred dallaa(SSW). 1,u owner of the pmpmy,Cir my employcu with wag"u their sole compenadlon. will do thematic.and the structure is not intended or Offered forsale(Ses.70".Business and Profession Code:The Coomctors License Law docs out apply to an nme,of Required Inspections property who builds Cir improves themon,and who docs such w"k himsel f or through his ownempioycu,provided Na such impf"emenu art not intended oroffesed torula 16 however,the building or improvement is sold within One year of completion,the ownCr. builder will have the burden of roving Na TO,did not build or improve for purpose of sate.). lgl,l.as owner of the pmpcny,am exclusively contracting with licensed conuumn o Comma the project(Sec.7014.Business and Profem ors,Code:)The Conaacols U- cove law does not apply to an owner Of property who builds or improves thereon,and, who contracts for such projects with a eonlfuor(O licensed pursuant o the Comuofs License I r. ne,Sc. ,B&Pcrmdd3mmn d' Daug ORKSCOMPENSATONDECTION /aT 7CC11Ihemyafsurate. paredly.f1dolOned0s, llwingdalarmons: I have and will main n a Certificate of Conant to self-insure for Workeh Compen. 3, ion,as provided far by Section 3700 of dte Labor Code,for the performance of the W for which this permit is issued. 1 have and will maintain Worker's Compensation hoodance,u returned by Section W of the tabor Code,for the perform.nce of Ne wok for which this permit is issued. y Wmime,Compewdon Ins .Cartier and Policy numberrver: Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE olusscetion need not M complcuJ ifthe permit Is intone hundred dollars($100) or less) 1 certify that in Ne Performance of be work for which this permit u issued.I shall not employ any person in any mannerm as In Isecome object o the Workeri Compensation Laws of California.Dau Applicant NOTICE TO APPLICANT.If,after making this Ccnilicale of Exemption,you should become subject to the Worker's Compmadon provision of the ISMf Cade,you moa v,Z forthwith Comply with such provision Or this Permit hall M deemed revoked. Z In CONSrRUCnON LENDING AGENCY [—, I hereby aRrm that Neo is a construction lending agency for the performance of a> IM work for which this permit is issued(Sec.3093.Civ.C.) 0 Lender's Come / 0, Lboderress s Add. V I ttNfy that 1 have read this application and sole Net the above information is IL m ma 1 pme o comply with all City and county on inancea and state laws misting to 0 building convection,and hereby mdurie mposenutives of this city in enter upon the �~ r[21 above-mentioned pmpeny for inspection purpose& 4. (We)agree no ave.indemnify std Feer,harnlm the City of Cupeftom paint / F'rq liabiliuu.judgmcnu,casts and expenses which may in xnywayattmeagainauid City / _/3 V Z inconcqumcc Ofthegrating Of Nispermit. Lll .. APP I ANT UNDE ANDS ND WILL COMPLY WITH ALL NON-POINT Issued by: Date S LA Sr Re-roofs RI ignuum o Apple m/CmuractmHAZARDOUS MATERIALS DISCLOSURE ate Type of Roof Will the applicant or fora Wilding Occupantsom or handle hudomous material as defined by Ne C.P.M..Municipal Code,Chapter 9.12.Bud the Health and Safety code.Section 255320)7 All roofs shall be inspected prior to any roofing material being installed. ❑Yen ON. If a roof is installed without first obtaining an inspection,I agree to remove Will the applicant or future building occupant use Nutriment or devices which .to h...Moo,air contaminants u defined by that Be,Am.Air Quality Management all new materials for inspection. District? ❑Y" 0N I have rtad theW d..smausaismquimmenuandcr Chapter6.95oftheCalifor- nix Hwllh&SafctyCOde,Savors 25505.25533 as125534.1 undcmand thaifda building does not currently haat a Mount.that it u my Mai aruibility o notify the occupant Of the cot him met'nrru"nanr.ocrupetedOccupancy. Signature of Applicant Date o rnranhndr<e,pen, te All roof coverings to be Class"B"or better Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 aCAF Fax(408)777-3333 UPEI,TINO Building Department JOB ADDRESS: PERMIT # O , 0 GO o� N 44*1Sj0&W7 DR 7 J U' OWNER'SNAME:W/,LFWRb Af /C PHONE # --79981 GENERAL CONTRACTOR: 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 b (,,, S Excavation Fencing Flooring: Carpeting Linoleum/ Wood Glass/ Glazing Heating �3L Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Ple 6&,1z& Q/ O er/Contractor Signature bate 1A CITY OF CUPERTINO COPE TING PERMIT APPLICATION FORM APN # Date: Building Address: , Mailing Address (if different from building address): d .! Owner's N Phone #: Contra tor: SyAA F0/P4 PC (11"461416 License #: ,✓ /,v 6 & `7 ontact: Phone: 8(, - gqS/ Cupertino Business License#: Fax: Building Permit Info: Bldg ❑ Elect Plumb Mech Job Description: fEP44rG &,V* C6" 46,0 Ar— / ps11VEc. 41,94,004 74 ?a M Residential Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: oU ost ofP ect:�z 1 � Occupancy Group: Type of Construction: / Please check this box if the project is a Adak FAf-V WL _ -4- second-story addition: ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING 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 <= IOOOA 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 �/X_ --,) S-o ? 7 1 of 3 2 7 (C - CITY OF CUPERTINO CUPEIZTINO PERMIT APPLICATION FORM QuantityFee ID Fee Description Fee Group BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BOVERTME 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 rinklerBackflo 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 cfin 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 I Remodel Res Appliance ELECTRICAL BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL 2of3 (CQ= CITY OF CUPERTINO CUP TYOF O PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Grou 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