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04040012 CITY OF CUPERTINO - ' ` '� BUILDING DIVISION PERMIT 4CONTI2ACTOR�INk'l)12MATION'"'r BUILDING ADDRESS: PERMIT NO. WILLOW GLEN ELECTRIC INC 04040012 OWNER'S NAME: PERMIT ISSUE DATE JENNIFER SANITARY 0 OL NO, ONE: ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LOO LICENSEDCONTRACTOR'SDECLARATION Job Description 1 hereby affirm that 1 am licenacd under provisions of Chapter 9(commencing with Section 7000)of Division 3 of Ne Buv2 ss.¢nd Pmfcuinna Code,antl my license is iZ,to n inrulllnman0effeccC/D 7" l;-9 _ ELECT PANEL UPGRADE (200A) j Licenx Clusx� Lie.M i Dam Codirector ! 2 foe) DEC ARCHITECTS DECLARATION 00 1 understand my plain¢h I. used as pntiiic retmNs% 4� -JyU 4,t; Licenae6 rt &atonal S OW B exempt EGE RATION .�1 .'�a I erehy affirm on 1 este exempt from die Contns Co Licenx Law for the l% i a O following reason(Section 703 1.5,Bbsimsa and Professions Code:Any tiny or county aa m� which reunites a pends.1 Ore, t,eller,improve,demolish, fife mash any sanctum He,nr its issuoncc,also requires die applicant for such permit m f Ie a signed statement �"`< Ihat he islicensed pursuanuo the provisions of the Conlnctori Licenx Law(Charter 9 Sq. Ft.Floor Area valuation FG (commencing with Section 701 of Division 3 of the Businessland limitations Code)or a.ey mm he is exempt dteref can and the basis for then alleged exemption.Any violation of Section?031.5 by any applicant for a permit subjects the applicant to a civil Penalty of 3A_FNft0er00 Occupancy Type not more titan five hundred dollars(55110). ❑1,as owner of the property,or my employees with wages as drain able compensation. will do me work,end Ne shuctox is not intended m cdered for sale(sec.704a,Rusiness Required Inspections and Professions Code The Convector's License Law docs not apply to an owner of q P property who builds or harrows thereon.and w he does such work hi msel f or through his own employees,provided thatsuch improvements arcnm intended muffered for sale.IL however.me building or improvement is sold within one year of completion,the owner- builder will have the burden of proving that he did not build or improve for purpose of sale.). 1,as most of Ne property,am exclusively connecting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:)The Comeador's Li- cense Law docs not apply to an owner of property who Wilds or improves thereon,and, who contends for such projects wit a contractor(&)licensed pursuant o the Counselor's License Law. ❑I am exempt undo Sec. B&P C for this mason Owner Data WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of Perjury one of die following declarations: 1 have and will maintain a Certificate of Cement 1.x161naum for Worker's Comfort- action,as provided for by Section 3700 of the Labor Code.for the performance of the work for which this permit is issued. ❑1 have and will maintain Workers Compensation Insurance,as,required by Section 3700 of the labor Code,for to performance of be work for which this Permit is issued. My Worker's Compensation Insurance carrier and Policy number am: ' t�-I"IQ f f G n Polic�.y�dk w�7.LZ22L11d1 Qatrier. UfiBO '\ ERTIFICATE OF EXEMPTION MWORKERS' 6D �O L� COMPENSATION INS RANCE L1 isarva nnCD'ot k completed if the permit is nonan hundred dollars(SRod Ides.) 1 certify that in the performance of the work for which this Permit is issued,l shall not employ any person in any manner so U to become subject to tk Workers'Compensation Laws of California.Date Applicant NOTICE TO APPLICANT.if,after making this Certificate of Exemption,you should become subject to the Worker's Compertulion provisions of the Later Codc,you must .J Z forthwith comply wadi such Provisions or mit Permit shall W deemed mamkcd. z O CONSTRUCTION LENDING AGENCY Ihcrcby affirm that there is a comslmninn lending agency for me performance of Cls> the work for which this permit is issued(Sec.3090,Civ.C.) W A Lender's Name z Lender's Add.. V Q I certify that I have read this application and state that the above information is IT, F cored.1 agree to comply with all city and county eminences and state laws relating to CU building construction,and hereby audience representatives of this city to enter upon the F U above-mentioned property far inspection purposes. /r(WC)agree to save,indemnify and keep harmless me City of Cupeftua egainsl V) Inthilities,judgments,coats and expenses which may in any way accmc ignire sou City 'J V z APPLICANTeUNDERSTANDSthis AND permit. WILL COMPLY WITH ALL NON-POINT Issued by: Date fl SOURCE REGULATI LY// lRe-roofs ig I rc bfApit a A in=S MATERIALS DISCLOSUA Dam Type of Roof Will the applicant or future building occupant than or handle ha�ous material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety 'Iffilwwo,Sccdon 25532(a)7 All roofs shall be inspected prior to any roofing material being installed. 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 emit harardnus air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. D'strin? ❑Yes RNu I have read thc haamous materials mquircments under Chapmr6.95 of the Califbr- niaHeolth&SafctyCnle,Sectiom 23505.25533 and 25534.1 uMduclo thallfthe building dors nbl currently have a Tenant,that it it my rcspbnsiolity to only the acolam of the requirements which must be tpnnMesswnd,or a Cdoneato of Occupancy. Signature of Applicant Dale y All roof coverings to be Class"B"or better Own tar audrecoo a ate Community Development 0 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 UPEkTIN® Building Deartmen� JOB ADDRES • 97ci 34 1' IT # /)y Q OWNER'S NAME 3e n r Ann >15HONE # g _ s GENERAL CONTRACTOR: FAX # I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: 60 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 17 L� c or a —'— a e CITY OF CUPERTINO CUP TYOF O PERMIT APPLICATION FORM ®APN # l �� Date: Building Address: Owner's Name: ezm3 w o Pena Phone#: F/ I J q U3 S Contractor. �� 1100 6(6-0 c4 1 G License #: e / ` Contact: M Cupertino Business License#: Building Permit Info: Bldg ❑ Elect 1K Plumb ❑ Mech ❑ Job Description: ResidentialZOOAWaco�e Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project'-u,' �- � Occupancy Grou Type of Constru tion: Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILERI Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> IOOK to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to 1M Btu MECHANICAL BBOILER4 Boiler> IM 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 > I OOOA ELECTRICAL 1 — 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 3 C/ �� CITY OF CUPERTINO CUP TYOF O PERMIT APPLICATION FORM QuantityFee 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 BNUMULTI 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 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 HeaterNent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfm MECHANICAL BREMAMHAN 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 J BREMPOLE Pole/Platform Fixture ELECTRICAL 2 of 3 r CITY OF CUPERTINO CUP TYOF O PERMIT APPLICATION FORM QuantityFee 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 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 BSPECL4L 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 Issuance PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING 3 of 3