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03070143 CITY OF CUPERTINO ✓�rK ``` '' " HUI LnING DIVISION PERMIT COW( ,RACiTOR�INFORMATION - . BUILDING ADDRESS: ( "'B" NOO 3 0 7 0 14 3 13259 1A TOT IA. QT- OWNER'S NAME7 PERMIT ISSUE DATE I E: SANITARY N0. CONTROL NO. ARCHITEC MNGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH Loo LICENSED CONTRACOWSDECLARATION Job Description I Wrchy affirm Nmen al 1 am licensed under Provisions or Chapter 9(comcing n� wiihS um7fkk0of Division3of NCB and Prufessinm Calomel my license is n ovum ana2rcen. se C'[O it ✓Lic.N cj C3�5 ADD 160 SQ. FT. KITCHEN REMODEL j�Z LicenL J LL � Dela carter CONTRACTOR: A-1 DESIGNS (07 //((((((�����3''''y222) ARCHITECTS ARATIO /�� ® ax �® demanJ la hall h Mi rt gyp\Wim! Dieu 3'V; Lice Its css noel 3 OWNER-BUILDER DECLARATION NOV 2 0 2003 .i I I mouth,affirm that I am exempt from the Convector's License Law for the i cO following reek. (S . ection 7031.5,Business and Professions Code:Any city or county v�a which requires a permit to construct.alms improve,demolish,or repair any nvuctum prior In its issuance,also acquires the applicant for such permit to file a signed statement that he is licensee pursuant m the provisions of the Cotnnclor'e License Law(Chapter 9 Sq. Ft. Floor Areabui OO a $ (commencing with Section 70M)of Division 3 of the Business and Professions Critic)or .. that he is exempt therefrom and the basis for the alleged exemption.Any vinlatian of Section 7031.5 by Any applicant for A permit subjects the applicant to e civil penalty of 3 j1l�vbliJ'raer0O Occupancy Type not..Nan I.hundred dollars(SSW). 0 1,a owner of the pmpmty,or my employees with wages As their sole compensation, will do the work And thear num is not intended or offered for gale(Sec.7014,Business and Profeuions Cade:The Contractor's License Law does not apply to an owner of Required Inspections property who builds or improws thenen,and who elms such work himaelfm through his 101 — FOUNDATION own employees,provided that such improvements are not intended m allured fa In.If, 102 — PIERS however,the building or improvement is gold within ane year of completion,the owner. Wilder will have the burden of proving that he did not Wild or improve for purpose of 103 - UFER gam... 104 - REBAR co I,ru owner of project property,am exclusively contracting with licensed onnv contractors to momsconstLa beees not apply to an ownBuser and Professions Code:) r Convoram, Li 105 — ANCHOR BOLTS. ccmelawdts for hpyman with aorpmperry who Wild, pursuant lhenemand, 106 — SEWER & WATER who contracts.for each prejecu with aeentnemr(q licensed purwmuo the Camnnors Lice Am law. 202 — UNDERFLOOR PLUMBING ❑lam exempt under Sec. ,B&PCfar this recon 203 — UNDERFLOOR MECHANICAL Owner Date WORKER'S COMPENSATION DECLARATION 204 — UNDERFLOOR FRAME I hereby Arm under penalty of perjury ane or the following dalantioAu: 205 — UNDERFLOOR INSULATION ,an and will maintain a Certificate of Consent to self-imum for Worker's Compete 301 — ROUGH PLUMBING n,ga provided for by section 37110 of the Labor Code,for the performance of the 3 02 — TUB & OR SHOWER work for which this permit is issued. ❑1 have had will maintain Worker's Compensation Incur am,As Acquired by Section 303 — ROUGH MECHANICAL 3700 ofthc lJbor Cade.fortW performance of the work for which Nis pemril is issued. 304 — ROUGH ELECTRICAL My Worker's Com coati ngn artier and Policy number am; 305 — FRAME C ' r. Policy No.: .�_ '� CERT FICATE OF EXEMPTION F oRKeas• _ 306 - HOLDOWNS 17 COMPENSATION INSU NCE 307 — INSULATION (This section need at be completed if the permll is sur oro hundred dollars Bi[Bit) 308 — SHEETROCK gar iota) I ccnify that in the performance,of the work for which this permit is issued.)shall nor 309 — EXTERIOR LATH employ any person in any manner sat As to became subjecue the Workers'Compensation 310 — INTERIOR LATH Laws of C.Iifmaf4.Doc Applicant 311 — SCRATCH COAT NOTICE TO APPLICANT.If.after making this cenirmate or Exemption,you shnule 313 - ROOF NAIL Wcome subject to the Workeri Compensation previsions or the Labor Cattle,you must 0z forthwith comply with such Provisions or this Permit hallthe deemed revoked. 501 — ,FINAL ELECTRICAL ENERGY z C CONSTRUCTION LENDING AGENCY 502 — FINAL PLUMBING ENERGY E ' Ihenby affirm .'them is A construction lending agency for the performance of C > the work for which thiapermelaissued(Sec.3097.Civ.C.) 503 — FINAL MECHANICAL ENERGY W^q 1<nen]Name 504 — FINAL BUILDING ENERGY az LcnderaAedresa 505 — FINAL ELECTRICAL, U O 1 ccnify that l have read this application and tote that the above information is 506 — GAS TEST IP. correct.I agree to comply with all city and county ordinances and&late laws relating to 0 U building construction,and hereby authorim representatives orbit city to he upon the FIN PLUMB G C a have mentioned property for inspeetion purposes. (We,)Agree to save,indemnify and keep humleu the City of Cupcnino Against 0 8 F I L .�i In Iiabilities,judgmenut,costs and expenses which mny in any way accmc against City 5 U7 in consequence of the granlingof this permit. APPLIC T UNDERSTANDS AND WILL COMPLY IT ALL NON-POINT Issued bY:5 ING Dat SOUR EGULATIONS. / Re-roofs AL PUBLIC WORKS re,afA Dhcan or Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occupant store or handle hanquous material as defied by the Cupertino Municipal Code,Chapter 9.11,and the Health and Safety Code.Seetion 25532k)? All roofs shall be inspected prior to any roofing material being installed. [3y. 4'n Will the applicant at future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove huvardnus air cnnlnmlmnts.defined by the Bay Arca Air Quality Management all new materials for inspection. Nell El Yea; No I have mad the haramous materials requirements under Chapter 6.95 of the Califnr. nix Hcalth&Sufety Code,Scclinna 25515,25533 cod 25534.1 undontand her if the building does" I currently hove a Roam,that it is my responsi hllity to nod I the oecupanl of the r ul cntswhichmuslbc cl,p' misses FCcnificalcaf cu Signature of Applicant Date 0 nermamhorivadepem a,a All roof coverings to be Class "B"or better r (d CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM 0 3 (-7 D 'CUPEkTINO PN # Date: Building Address: Mailing Address (if different frdm building address): O I I e,- e� Owner's ame: f. Phone#: 0 9 Contractor: License#: ej-' N'�W.- Contact: Phone: Cupertino Business License#: Fax: Building Permit Info: Bldg Elect Plumb EK Mech ❑ Job Description: JG,'JC6L6w If" "ORI 'n Residential ISS 0 0 k ; Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: / Occupancy Group: Type of Construction: Please check this box ittheivr6ject is a second-story addition: ❑ Quantity Fee ID Fee Description Fee Grou BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits : foot BUILDING BBOILERI Boiler<= 100,000 Btu MECHANICAL 7 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 BMITIGATC Comm. Housing Mit. Fee BUILDING 1 of (d- CITY OF CUPERTINO CTMO 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 . BNUMULTI New Multifamily Res PLUMBING BOVERTEVIE Inspection Overtime BUILDING BPBACKFLOW Atmos beric 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 Stom7/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 BREMAIRHAN A/C Units <= 10,000 clip MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace> I 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 2 of 3 \ CITY OF CUPERTINO CITYOF PERMIT APPLICATION FORM CUPEkTINO u Fee ID Fee Description Fee Group 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 BSPECIAL Special Insection 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 j 3 of 3